PACES Flashcards

Question

Atrial fibrillation (AF) * Def? Causes? Ix? Mx?

Answer 1

**Def:** rapid, chaotic, and ineffective atrial electrical conduction * ECG def: irregularly irregular narrow complex tachycardia with no p waves **Causes:** idiopathic, cardio (**IHD**, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol **Ix:** ECG (absence of p-waves, irregularly irreg rhythm) * Echo (valve check) * Bloods - U&E, Mg (QT interval), Troponin (ischaemic), TFTs **Mx:** * Haemodynamically unstable (≤90 BP, chest pain, acute HF) --\> DC Cardioversion OR * Rate control --\> **B-blocker** (bisoprolol) OR rate-limiting CCB (verapamil - asthma) OR * Rhythm control - ONLY if clear reversible cause * Sx onset **\<48hrs** --\> **DC/chemical cardioversion** (amiodarone/flecanide) * NOTE: IV heparin started prior to cardioversion * Sx onset \>48hrs --\> _anticoagulate for 3wks_ --\> elective cardioversion (also anticoag for 4wks after) AND * Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score --\> DOAC (Apixaban) * If metallic heart valve --\> warfarin INR 3-3.5 * Otherwise DOAC * NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 --\> anticoagulation not recommended * **C**HF, **H**TN, **A**ge ≥75rs (2), **D**M, **S**troke (2), **V**ascular disease, **A**ge 65-74, **S**ex - female * Score 1 - consider; ≥2 - DOAC/Warfarin needed * Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)

Answer 2

Def: infection of heart valves (typically mitral/aortic or _tricuspid in IVDU_) RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings Presentation: low-grade fevers, night sweats * Exam: * Splenomegaly * _Splinter haemorrhages_, osler's nodes, Janeway lesions, petechiae, Roth spots (eyes) * Chronic = clubbing (rare, mostly acute now) **Ix:** * Urine dip - haematuria * _Serial BCs_ (x3 but start empirical abx), ESR * _Transoesophageal Echo_ (TOE - vegetations) **Dx: _DUKE’S CRITERIA_** (2 major OR 1 major + 3 minor OR 5 minor): * Major**: +ve BC** (typical organism), **new regurg murmur/veg on echo** * Minor: RF, fever (\>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism) **Mx**: IV abx for 6wks – fluclox/vanc/gent **Acute** in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly _S. aureus_ (also most common cause in _prosthetic valve endocarditis_) **Subacute** in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly _Strep Viridans_ (overall most common cause of endocarditis)

Answer 3

3rd = rapid ventricular filling = **_volume overload_** e.g. **HF** (reduced EF/systolic) * KEN...TU.CKY (deee. de.de) 4th = atrial contraction against stiff ventricles = **_pressure overload_** e.g. **longstanding AS** & other causes of left ventricular hypertrophy (HTN heart disease**,** HOCM, HF with preserved EF/diastolic) * TE.NE..SSEE (de.de.deee)

Answer 4

Pericarditis Causes: * Viral (most common) * MI (can be Dressler's syndrome) * TB (constrictive) * Uraemia (CKD where urea high --\> pericarditis) = indication for haemodialysis (HUMP) * Hydralazine (AI pericarditis) * NOTE: also causes _drug-induced lupus_ * SLE, RF, radiation Presentation: * Pleuritic chest pain, worse lying flat * Exam: pericardial rub - "creaking/scratching" * Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration Ix: * ECG: ST elevation widespread * Only slightly raised/normal troponin Mx: **_colchicine (3 months)_** + NSAIDs (ibuprofen, max 2wks)

Answer 5

JVP + hepatojugular pressure (RUQ), rockstar hand **PQRST:** * **P**ul HTN/PE/Pericarditis/Pericardial effusion/PS * **Q**uantity of fluid (fluid overloaded) * **R**HF * **S**VC obstruction * **T**amponade/TR

Answer 6

Presentation: swollen face and neck and distended veins on her chest in background of cancer Mx: dexamethasone to reduce tumour swelling * Insert EV stent if stridor (after intubation and steroids)

Answer 7

Innitial: A-E * If unstable - 500mcg IV atropine (/5mins up to 3mg) * Also considered unstable if: * Recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block * Caution in acute MI, C/I if heart transplant * If persistent --\> transcutaneous pacing + analgesia/sedation (very painful) * If can't be achieved properly --\> IV isoprenaline/adrenaline (specialist help) * Arrange transvenous pacing (temporary if recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block)

Answer 8

Causes: * MI/IHD (MOST COMMON) * Inf (RHD, IE) * Drugs (digoxin) * Metabolic (hyperkalaemia) * Infiltration of conducting system (e.g. sarcoidosis) * Degeneration of conducting system Types: * First Degree AV block - fixed prolonged PR interval (\> 0.2 s) - _ASYMPTOMATIC_ * Second degree AV block: * Mobitz TI (Wenckebach) - progressively prolonged PR interval --\> P-wave NOT followed by a QRS complex = 'going, going, gone' * _Normally asymptomatic_ * Mobitz Type II - intermittently P wave NOT followed by a QRS * May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1) * Can cause: * Stokes-Adams Attacks (syncope caused by ventricular asystole) * Dizziness, palps, chest pain, HF * Complete AV heart block - no relationship between P waves and QRS complexes * Presentation as in Mobitz T2 Ix: ECG * Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP) * CXR (cardiac enlargement, pulmonary oedema) * Echo (wall motion abn, aortic valve disease, vegitations) Mx: * Acute block - if clinical deterioration: * IV atropine * Consider temporary transcutaneous pacing * Chronic block: * 1st degree monitored * Permanent pacemaker in: * Symptomatic Mobitz T1 * Advanced Mobitz T2 * Complete heart block Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion

Answer 9

**VT** or SVT w/ aberrancy * SVT \>200bpm, also often irregular * VT more likely if LAD * Acutely treat any broad complex tachy as VT until proven otherwise Presentation: _palpitations, light-headed, chest pain_, syncope, seizure * Tachycardia, LVF * ACS most common cause * **_NEVER IGNORE palpitations & light-headedness_** Ix: ECG - regular broad complex tachycardia * U&E (Mg, Ca, K), TFTs, Troponins Mx: * Unstable tachycardia (BP \<90, chest pain, acute cardiac failure) = _DC cardioversion_ * Stable: * Prepare for DC cardioversion * IV amiodarone, b-blocker

Answer 10

Types: * Implantable Cardioverter Defibrillator (ICD, has a thicker end) * Single-chamber pacemaker (right ventricle) * Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction) * Rarely can have atrial lead only - if SA disease in young with good AV conduction * Dual-chamber pacemaker (right atrium & ventricle) * Can have ICD dual-chamber pacemaker * Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead) * Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead) * Can have ICD biventricular pacemaker When to use each type: * Atrial lead only → Sino-atrial disease in young people with good AV node conduction * RV lead only → Pacing whilst in _permanent atrial fibrillation_ * Dual-lead → All other scenarios (paroxysmal AF, bradycardia) * CRT → LV dysfunction + broad QRS --\> _end-stage HF_ * Indications for ICD: * Primary prevention = **@risk of serious ventricular arrhythmia** * Familial cardiac conditions (hypertrophic cardiomyopathy, long QT) * Previous surgical repair of congenital HD * Previous MI + LVEF \<35% + HF Sx * Secondary prevention = **had previous serious ventricular arrhythmia _wo/ treatable cause_** * Cardiac arrest from VT/VT * Spontaneous sustained VT AND: * Syncope/haemodynamic compromise OR * LVEF \<35% + sign HF Sx (NYHA 3+) * NOTE: VT/VF from STEMI has treatable cause (open occluded vessel) Complications: * Surgical complications - infection, bleeding, damage to underlying structures * Displacement (of lead) * Pacemaker syndrome (if ventricular lead with no atrial) --\> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx

Answer 11

Tricuspid regurgitation Complete heart block Acute cardiac tamponade/Constrictive pericarditis

Answer 12

Aspirin prn Benzylpenicillin IM stat --\> 10 day course of benzylpenicillin PO

Answer 13

1. Treat underlying cause 2. Anticoagulate as you would for atrial fibrillation If haemodynamically unstable: rate control or cardioversion

Answer 14

What: * 'Rumbling mid-diastolic murmur' * Associated with severe aortic regurgitation * Best auscultated in 5th ICS in MCL * Caused by blood flowing back through the aortic valve and over the mitral valve When: * Mid-diastole * Caused by regurgitant jet that runs over the mitral valve leaflets

Answer 15

Pulsus paradoxus - BP variation between inspiration & expiration (≥10) **Beck's triad** (50%): * Raised JVP * Muffled heart sounds * Hypotension Mx: * _IV fluids_ (RV filling depends on venous pressure & effusion is constricting) * Echo --\> refer to cardiology for pericardiocentesis * Coagulation profile (to prep for pericardiocentesis)

Answer 16

* Midline sternotomy + leg scar = CABG * Midline sternotomy (no leg scar) = Valve replacement most likely (rarely can be CABG without vein graft) * Left subclavicular -\> pacemaker, debfibrillator, resynchronisation device * L shaped scars under either breast -\> L/R Thoracotomy

Answer 17

ASD - commonest is _ostium secundum_ * Mid-diastolic murmur + fixed split S2 * High risk of AF & paradoxical emboli (prev stroke?) * NOTE: commonest inherited cardiac condition to present in adulthood (as can be asymptomatic in childhood) * NOTE: this is not Eisenmenger's syndrome as patient not cyanotic Assoc w/ down's syndrome (& AVSD), Turner's & Noonan's syndrome Ix: * ECG - _incomplete RBBB_ (90%, can be normal variant), RVH (T-wave inversion V1-3), P pulmonale (tented P-waves), AF * Ix: _bubble study_ (+ RV dilatation) * Also done for patent foramen ovale (PFO)

Answer 18

Def: chr inflamed pericardium (this is why colchicine is given for 3 months in normal pericarditis) Cause: classically previous TB in the pericardium Ix: * (Exam - pericardial knock on auscultation (bit old school)) * Kussmaul's sign - JVP rises on breathing in * _Small heart on CXR_ ± calcifications * Low voltage ECG w/ T-wave inversion/flattening (could also be pericardial effusion) Complication: _cardiac liver cirrhosis_ * Right ventricle struggles --\> tricuspid regurg (pulsatile liver) --\> liver failure (oedema +++)

Answer 19

Young + very high BP --\> must be _secondary HTN_ (causes: endo - Conn's, Phaeo; coarctation of Aorta (CoA), renal artery stenosis, chronic renal failure) **CoA** - tissue restricting flow across aortic arch * Murmur across the coarctation = _left infrascapular area_ (due to turbulent BF) * Lower body underdeveloped vs upper (97% men going to gym) * Assoc: **_Turner's_** (+ Marfan's, Ehlers-Danlos) * Short stature, webbed neck, wide-spaced eyes, lack of other secondary sexual characteristics, shield-like chest, short 4th metacarpals/tarsals * Advice: avoid extreme isometric exercises e.g. weight-lifting --\> risk of _aortic dissection_ * How do you Dx dissection? CT aortogram w/ contrast

Answer 20

* Not palpable * Double pulsation * Obliterated when pressure applied at base of neck * Rises with hepatojugular reflux * Height changes with respiration

Answer 21

Cause of hepatic decompensation in CLD: * _Hypokalaemia_ * _Constipation_ (given lactulose in hospital) * Alcohol * GI bleed (lots of protein (Hb) enters the bowel --\>liver can't cope) * HCC Decompensated CLD --\> **_Ascites_, jaundice & encephalopathy** * Severely scarred liver (cirrhosis) in CLD --\> back pressure on portal vein --\> **PORTAL HTN** = _splenomegaly, ascites, varices_ - caput medusae, oesophageal & rectal Ix: * **_Serum Ascites Albumin Gradient (SAAG)_** - serum albumin conc vs ascites conc - 11.1g/L * **\<11.1g/L = exudative cause** - infection - TB/inflammation - pancreatitis/malig (albumin leaking into ascites) OR nephrotic syndrome (pee out albumin so low serum albumin) * Otherwise = transudative cause - portal HTN (Cirrhosis), renal failure, HF * \>250 neutrophils = **spontaneous bacterial peritonitis (SBP)** --\> Tazocin/3rd gen cephalosporin * If protein conc \<15g/L give prophylactic oral ciprofloxacin Mx: * **Paracentesis** (ascitic drain) --\> _post-paracentesis circulatory dysfunction_ (drops BP) SO if \>5L drained give human albumin solution (HAS) 8g/L drained * **Spironolactone** (2nd line - Furosemide) - to prevent fluid accumulation * (Salt restrict) * **Hepatic encephalopathy** (liver not dealing with toxins) - give **_Lactulose + Rifaximin_** to prevent * **Coagulopathy** - OGD (check for varices) + vit K (needed for clotting)

Answer 22

**Functions of the liver --\> failure:** * Albumin (plasma oncotic pressure) --\> **oedema** * Bilirubin metabolism --\> **jaundice** * Clotting factors --\> **coagulopathy** * Detoxification --\> **encephalopathy** **Causes:** * **Common** - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis) * **Less common** - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson's disease Ix: * Alcohol history * Hep B/C serology * Ferritin, transferrin, A1AT, ceruloplasmin (Wilson's) * Ig, auto-abs (ANA in AI hep, AMA in PBC) Important complication = **_VARICES_** * Normal venous return: GI tract --_hepatic portal vein_ --\> liver --\> _hepatic vein_ --\> systemic circulation * Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum * MEMORY AID: **BUTT, GUT, CAPUT** * Pathological process: * In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein --\> reducing blood flow to the systemic circulation * Backflow of blood to the hepatic portal vein = increased --\> backflow to hepatosystemic anastomoses: * Oesophagus --\> **Oesophageal varices** * Spleen --\> **Splenomegaly** * Umbilicus --\> **Caput Medusae** * Only from portal HTN if running from below umbilicus up * Rectum --\> **Rectal varices** Score for prognosis & need for liver transplant = **Child-pugh score** (A = 5-6; B = 7-9; C = 10-15 --\> C is most severe)

Answer 23

**Pre-hepatic** - unconjugated bilirubin comes from breakdown of RBCs * _Haemolysis_ related-causes (excess prod) - AIHA, SCD, G6PD def, malaria * Ix: * Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it) * Urine: normal (unconjugated bilirubin is insoluble) * Stool: normal as liver functioning normally **Hepatic** - bilirubin absorbed into liver --\> conjugated --\> excreted via biliary tract into duodenum * _Liver disease_ related-causes - cirrhosis, hepatitis, Gilbert's syndrome, drugs * Ix: * Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation) * Urine: dark (leaked conjugated bilirubin is soluble) * Stool: slightly pale (reduced conjugated bilirubin to GI tract) **Post-hepatic** - conjugated bilirubin --\> soluble urobilingogen (yellow): 1) Absorbed into circulation --\> excreted via kidneys 2) Remaining --oxidised--\> stercobilin (brown) * _Biliary disease_ related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC * Ix: * Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can't reach duodenum and instead leaks into blood) * Urine: dark (leaked conjugated bilirubin is soluble) * Stool: very pale (no conjugated bilirubin reaches GI tract --\> no stercobilin generated)

Answer 24

**IBD** * _Truelove & Witts'_ severity index = severity criteria for IBD * **Crohn's disease** * **Sx:** **RIF pain** (terminal ileum), failure to thrive (incl. between attacks) * **Distribution:** _mouth to anus_ (esp. terminal ileum), skip lesions * **Histology:** transmural, non-caseating granuloma (also in sarcoidosis) * **Ix:** * OGD/colonoscopy/capsule endoscopy * Gastografin follow-through * **Mx:** * Induction: * **Steroids** (induce remission) * 5-ASA (mesalazine) * Maintenance: * Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine) * Biologics e.g. Anti-TNF (infliximab) * **Ulcerative colitis** * **Sx:** **gen. abdo pain**, **PR blood** & mucus * **Distribution:** ONLY _rectum & colon_, continuous * **Histology:** mucosa & submucosa, mucosal ulcers, crypt abscesses * **Ix:** * Flexible sigmoidoscopy/colonoscopy * **Mx:** * Induction: * **5-ASA** * Steroids * Maintenance: * **5-ASA** (mesalazine) * Steroid-sparing agents (azathioprine) * Biologics (infliximab) * Surgery (proctocolectomy, IJ pouch) **Coeliac disease** * **Def:** inflammatory response to gluten (immune reaction to gliadin) * DQ2/8 (on HLA typing) * **Sx:** abdo Sx (**_steatorrhoea_**, diarrhoea, bloating), failure to thrive * Exam: blistering rash on both knees. aphthous mouth ulcers * Assoc: T1DM * **Distribution:** duodenum * **Histology:** **_subtotal villous atrophy with crypt hyperplasia_** * **Ix:** (maintain normal diet - eat gluten for 6wks before testing) * Haematinics - macrocytic anaemia, low Fe, B12/folate * Serological testing: * Screening: **Anti-TTG** & _total IgA_ (check for selective IgA def in case this caused false '-ve' anti-tTg abs) * If weakly +ve --\> _anti-endomysial abs_ (more sensitive & specific) * OGD & **duodenal biopsy** * Histology: _sub-total villous atrophy with crypt hyperplasia_ * **Mx:** gluten avoidance **Irritable bowel syndrome** - Dx of exclusion * **Sx:** bloating, related to stress, diarrhoea/constipation, relieved by defecation * **"Pellet-like stools"** * **Ix:** **_faecal calprotectin_** (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD) * Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants

Answer 25

**Liver** - raised AST + ALT * Causes: viral/alcoholic hepatitis, hepatotoxic drugs * Most causes _increase in ALT \> increase in AST_ **EXCEPT** Alcoholic hepatitis - _AST 2x \> ALT_ * AST also rises in muscle damage e.g. MI (normal ALT) **Biliary** - raised GGT + ALP * Causes: gallstones, cholecystitis, cholangitis, PSC/PBC * NOTE: acute alcohol intake increases GGT * NOTE: ALP can come from _BONE_ (& placenta) - only biliary if GGT also raised

Answer 26

**Reason to do AXR:** worried about bowel obstruction (small/large bowel) **Small bowel obstruction** on AXR: * valvulae conniventes (from one wall to other) * Central to image * \>3cm distension * _Causes:_ **adhesions** (surgery, sepsis), hernia, neoplasm, volvulus, IBD **Large bowel obstruction** on AXR: * Haustra (Not full width of bowel) * Outsides of image * \>6cm distension * _Causes:_ **neoplasm,** diverticular disease, volvulus, faecal impaction _NOTE:_ 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm) **Volvulus signs** (twisting of loop of bowel on mesentery --\> balloon animal): * **Coffee bean sign** - sigmoid volvulus (large bowel just before rectum) * **Embryo sign** - caecal volvulus (large bowel just after small bowel)

Answer 27

* **PSC** - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice) * **Associations:** _UC_ (10% but 80% PSC have UC), _Cholangiocarcinoma_ * **Ix:** MRCP, pANCA * 'Beads on string' on ERCP * **Tx:** supportive, liver transplant * **PBC** - intrahepatic only (benign condition - middle-aged female, intractable itching) * **Associations:** _AI diseases_ (RA, Sjogren's, hypothyroidism) * **Sicca syndrome** (70%) - dry eyes & mouth (like Sjogren's syndrome) * Fat malabsorption w/ steatorrhoea (incl vitamins ADEK): * Low vit D can cause _osteomalacia & proximal myopathy_ *e.g. difficulty climbing stairs & pain in lower back* * Low vit K can cause coagulopathy * **Ix:** _anti-mitochondrial Ab (AMA)_, high cholesterol * **Tx:** ursodeoxycholic acid (prognostic benefit)

Answer 28

**Blood supply** * **Coeliac axis** - oesophagus, stomach, start of small intestine * **Superior mesenteric artery (SMA)** - most of the small intestines up to 2/3 transverse colon * **Inferior mesenteric artery (IMA)** - from 2/3 along transverse colon down to rectym * NOTE: area 2/3 along transverse colon @splenic flexure = **_WATERSHED ZONE_** (limited supply from superior & inferior mesenteric arteries) --\> _vulnerable to ischaemia!!_ **__Mesenteric ischemia** * **Acute** - occlusion of SMA by thrombus/embolus * **Sx:** severe abdo pain, normal abdo exam, shock * **Ix:** * _AXR_ (gasless abdo) * _VBG_ (lactic acidosis) * **CT abdo with contrast** (if suspect mesenteric ischaemia)/**CT angiogram** (if LA) * If not primary surgery --\> followed by _mesenteric angiography_ (Dx non-occlusive mesenteric ischaemia) * Mx: resus + CCOT + NBM * Empirical abx * Bypass ± bowel resection * Heparin post-op * **Chronic** - narrowing of SMA by atherosclerosis (stable angina of bowel) * **Sx:** colicky post-prandial abdo pain (more work for bowel to do --\> pain, just like in stable angina & exercise) * Ix: as above * Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery) **Ischemic colitis** * Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus * **Sx:** abdo pain, PR bleeding * **Ix:** sigmoidoscopy/colonoscopy * Mx: seek GI & surgical input (can develop chr ulcerating IC) * Mild - conservative (IV abx, fluids, bowel rest, DM control) * Prophylactic LMWH * Segmental resection + stoma

Answer 29

**Hepatomegaly causes:** * _Hepatitis (infective and non-infective)_ * _Hepatocellular carcinoma/hepatic mets_ * Wilson’s disease, Haemochromatosis * Primary biliary cirrhosis * Leukaemia, Myeloma, haemolytic anaemia * Glandular fever * Tricuspid regurgitation **Splenomegaly causes:** * _Portal HTN secondary to liver cirrhosis_ * Splenic mets * Haemolytic anaemia, Congestive HF, Glandular fever **Large kidney causes:** * Bilaterally enlarged: _polycystic kidney disease, amyloidosis_ * Unilaterally enlarged: _renal tumour_

Answer 30

Nodosum - pain over shins Multiforme - target lesions (life-threatening = Steven's Johnson Syndrome) Ab igne - hot water bottle (chr heat exposure) Marginatum - acute rheumatic fever Chronicum migrans - lyme disease

Answer 31

**Hep A:** faecal-oral --\> acute **Hep B:** blood-borne --\> acute/chronic --\> serology * Contains: Core Ag (cAg), E Ag (eAg), DS-DNA, surface antigens (sAg) * eAg present if active & infective * Infection response --\> generate sAb (surface) + cAb (core) * Vaccination gives sAg (no reproductive capacity) --\> develop sAb (but not cAb) * Serology: * HB**sAg**/HB**eAg** - actively infecte * IgM = acute; IgG = chronic * _eAg = highly infective_ * HB**sAb** - protective (cleared/vaccinated) * HB**cAb** - only if previously cleared * Can be assoc with Polyarteritis Nodosa (vasculitic rash) & mononeuritis multiplex * Tx: IFN-alpha & lamivudine **Hep C:** blood-borne --\> _chronic_ --\> HCV RNA * More likely to become chronic than Hep B * Assoc w/ _mixed cryoglobulinaemia_ (purpuric skin lesions, Raynaud's phenomenon) * RF +ve, low C4, normal C3 * Can have +ve anti-LKM1 ab (also in AI hep) * Tx: PEG-IFN alpha & ribavirin Hep D: blood-borne --\> co/superinfection w/ Hep B virus Hep E: faecal-oral --\> acute, pregnancy

Answer 32

GOR(D) * external **G**enitalia * hernial **O**rificies * digital **R**ectal

Answer 33

RFs: * Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA) * Genetic predisposition: * For T1 AIH - HLA-DR3/4 * For T2 AIH - HLA-DQB1/DRB1 Ix: * Anti-smooth muscle Ab (SMA), ANA * T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA * T2: anti-LKM1 Mx: high-dose prednisolone + long-term azathioprine Complications: * Cirrhosis in 40%, relapse high if stop IS

Answer 34

**Spleen (vs kidney):** * Moves down with inspiration * You can’t get above it * Has a notch * Dull to percussion & not ballotable

Answer 35

**Blatchford score** Variceal bleed * Massive haemorrhage --\> balloon tamponade * A-E assessment --\> IV fluids, blood transfusion * F1 Essentials: * 2x large bore cannula * VBG * G&S/X-match * Bleep the bleed reg * Drugs with prognostic benefit: * IV Terlipressin (ADH analogue --\> vasoconstriction)/Somatostatin (used for same reason) * Prophylactic abx - Ceftriaxone/Norfloxacin (abx) * Intervention (discuss with on-call bleed registrar) --\> endoscopic band ligation

Answer 36

RFs: * H. pylori exposure * Aspirin/NSAID use Types: * Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ _NSAIDs_ * Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ _H. pylori_, worse by stress/at night --\> radiates to back, put weight on, malaena * Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum --\> likely cause of bleeding in PUD Presentation: * Chr/recurrent upper abdo pain - related to eating & nocturnal * Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas * Pointing sign on exam - show where pain is with 1-finger * NOTE: 'Coffee grounds' vomiting = upper GI bleed (mostly due to PUD \> gastric erosions) Ix: * **OGD endoscopy** = gold-standard * Immediately if dyspepsia + upper GI bleed * Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain --\> exclude malignancy * Repeat within 6-8wks to ensure ulcer healing/rule out malignancy * **H. pylori stool antigen**/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx) * Bloods - FBC Mx: consider **STOPPING NSAIDs** * Active bleed: * Urgent evaluation (A-E + **Blatchford score**) + blood transfusion * **OGD endoscopy** (Dx & Tx) --\> high-dose IV PPI afterwards (continue oral PPI for 6wks) * **Rockall score** (for risk of rebleed/death) --\> if re-bleed --\> repeat endoscopy & Tx endoscopically/emergency surgery * If H. pylori +ve: * **H. pylori eradication - triple therapy for 7 days** (**PPI** + 2 abx = **Amox** + **clari**/metro) --\> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx) * If pen allergic --\> PPI + Clari + Metro * If long-term NSAID/aspirin use: * Consider stopping NSAIDs/aspirin * Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks --\> H. pylori eradication afterwards * If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist) * If recurrent/refractory ulcers --\> long-term PPI/H2 antagonist

Answer 37

Dx: Wilson's disease (AR) * Neuropsych issues + liver involvement (no increased risk of HCC unlike haemochromatosis) * Basal ganglia degeneration - movement disorders, dysarthria Ix: * Conservative: * Urinalysis - elevated urinary copper * _Kayser-Fleischer rings_ on slit-lamp exam * Bloods: hepatic bloods, **reduced serum ceruloplasmin** * Genetic testing (trinucleotide repeat) - condition appears earlier & earlier each generation Mx: **chelation w/ penicillamine**

Answer 38

Dx: GORD * Decreased lower oesophageal sphincter (LOS) pressure: * Drugs - nitrates, CCBs (smooth muscle relaxation) * Alcohol, smoking * Hiatus hernia Presentation: RFs (above), heartburn (worse lying down/at night), reflux incl bitter taste in mouth (after meals) Ix: * 8wk PPI trial * If dyspepsia consider _OGD_ for: **anaemia, weight loss, dysphagia, \>55yrs** * Oesophageal pH study (\<4 for \>4% of time = GORD) Mx: * Conservative: weight loss, smoking cessation, head of bed elevation/avoid eating late at night, reduce alcohol * Medical: * Standard-dose PPI (20mg omeprazole) - continued long-term (if Sx continue after stopping/erosive oesophagitis/Barrett's oesophagus) * H2 antagonist (e.g. cimetidine) * Surgery (only if PPIs work but don't want long-term medical Tx) e.g. laparoscopic fundoplication Complication: Barrett's oesophagus --\> oesophageal adenocarcinoma

Answer 39

Def: tears of the squamous lining of the distal anal canal * \<6 weeks = acute, ≥6wks = chronic * 90% @posterior midline RFs: constipation, IBD, STIs (HIV, syphilis, herpes) Presentation: painful, bright red, rectal bleeding Ix: PR exam Mx: * Acute \<1wk: * Soften stool - high-fibre diet + high fluid intake, fybogel (2nd - lactulose) * Lubricants (for passing stool), topical anaesthetic, analgesia * Chronic: maintain above + topical GTN * After 8wks (if above not effective) --\> GI referral for sphincterotomy (or botulinum toxin)

Answer 40

Presentation: rectal bleeding & perianal pain Grading: * 1 - prominent BVs (no prolapse) * 2 - prolapse on bearing down + _spontaneous reduction_ * 3 - _manual reduction_ * 4 - _can't be manually reduced_ Ix: * Bedside: Anoscopic exam, stool (occult haem) * Bloods: FBC * Imaging: Colonoscopy/flex sigmoidoscopy Mx: * Conservative - fibre, fluids * Medical = **G1** - topical CS * Surgical: * **G2/3**: band ligation * **G4**: surgical haemorrhoidectomy

Answer 41

Dx: haemochromatosis * Risk of HCC (hepatocellular carcinoma) Classification: * Hereditary - AR, gene on chr6 (carried by 1:10 Europeans) * Secondary e.g. from frequent blood transfusions (SCD) Presentation - from Fe-deposition in various tissues: * Arthritis (esp hands), bronze DM (tan), cirrhosis * Hypogonadism (accumulates in testis) * Dilated cardiomyopathy (accumulates in heart) * XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis Ix: * Blood iron profile: * **TF saturation high** (\>55% men, \>50% women) * Ferritin normal/slightly high (\>500) * Low TIBC (as all transferrin saturated) Mx: * **Venesection** (until transferrin saturation normal) * **Desferrioxamine** (iron chelator to prevent recurring) * Monitoring ; TF saturation \<50% & serum ferritin \<50ug/l

Answer 42

ABC-\>P * Appendix * Bleeding/bowel obstruction/BV obstruction * GI bleed * Obstruction - small/large, mechanical/non-mechanical, complete/incomplete * Ischaemia/infarct * Cholecystitis/angiitis * Pancreatitis/Perforation (upper/lower GI)

Answer 43

Def: protrusion of a viscus through its wall Types: * Incisional hernia - iatrogenic following surgery * Groin hernia - ASIS & pubic tubercle palpated: * Femoral (W\>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation * **Inguinal** - above & medial to the pubic tubercle * Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring * Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring * Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear * Other groin lumps: * Lymphadenopathy - along inguinal ligament * Vascular - pulsatile varicose veins below inguinal ligament Mx: surgical (mesh) NOTE: hernias are safer the larger the defect as less likely to strangulate

Answer 44

* Midline sternotomy - AAA, laparotomy * Rooftop scar - liver transplant, Whipple's procedure, gastric surgery, oesophagectomy * Kocher – open gallbladder surgery * Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick) * Lanz/McBurney’s = Appendicectomy * Pfannenstiel = C-section/prostatectomy/cystectomy

Answer 45

Presentation: * Bowel habit change * Palpable mass * IDA, PR bleed (clots, fresh) * Acute (obstruction, perforation) Ix: colonoscopy Mx: based on TNM staging post-CT * Colon cancer * T4 (local advancement) --\> neoadjuvant Tx * Otherwise --\> colonic resection --\> if T3+/nodal disease --\> adjuvant chemo * Rectal cancer * T3-4 --\> neoadjuvant Tx --\> colonic resection --\> if T3+/nodal disease --\> adjuvant chemo * T1-2NOMO --\> transanal excision Screen: 60-74yrs FIT testing (or FOB)

Answer 46

**RFs (5Fs):** Fat, Female, Fertile, Forty, Fair **Types of gallstone:** mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous) **Biliary colic:** * **Def:** pain due to blockage of bile flow due to a gallstone * **Presentation:** RUQ pain, worse after fatty meals (stimulates gallbladder contraction --\> bile release for fat emulsification) **Cholecystitis:** * **Def:** inflammation of the gallbladder (typically in context of gallstones) * **Presentation:** RUQ pain (+ tenderness - Murphy's sign), _FEVER_ * Murphy's only +ve if not present on the left as well * Ix: * Urine dip – infection, bHCG * Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen * Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum) **Ascending cholangitis:** * **Def:** inf ascending the biliary tree, usually in the context of gallstone * **Presentation** (due to obstruction of Common Bile Duct - bile stagnates and becomes infected): * Charcot's triad - RUQ pain, fever, _JAUNDICE_ * Reynold's pentad (severe) - above + **shock** + **confusion** * **Surgical EMERGENCY** - Mx via _sepsis 6_ protocol (abx = Tazocin) + drain obstruction: * **Endoscopic retrograde cholangiopancreatography (ERCP)** - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system * Complications: **_pancreatitis_**, bleeding (from dilation of AoV), perforation * **Percutaneous transhepatic cholangiogram (PTC)** - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree --\> dislodge stone/alternative route for bile to flow - leave in cholecystostomy * **Cholecystostomy** - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy * Patients will likely require a later _cholecystectomy_ (after dealing with the acute infection)

Answer 47

Presentation: * Acute umbilical to _RIF pain_ (McBurney's point) * Tenderness + guarding (if rigid abdo - perforated apendix) * N&V --\> anorexia (not wanting to eat anything from nausea), change in bowel habit * Rovsig's sign - pain in RIF on LIF palpation * Psoas sign & Obturator sign DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction Ix: * Urinalysis, bloods - FBC, U&E, CRP * USS abdo/pelvis --\> consider contrast-enhanced CT-AP **Alvarado score** - \>4 = likely appendicitis Mx: * A-E (incl. fluids) * Sepsis bundle - abx when Dx confirmed * **Laparoscopic appendicectomy** * Conservative only if uncomplicated appendicitis

Answer 48

**Immediate Mx:** * NBM, _Ryles tube_ (aspirate stomach contents) * IV fluids * AXR -\> CT (identify transition point of obstruction) **Small bowel obstruction:** * _Causes_: _Adhesions_ (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian) * _Features_: central dilated loops of bowel, \>3cm, valvulae coniventes * _Mx_: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative) **Large bowel obstruction:** * _Causes_: tumour, volvulus * _Features_: peripheral dilated loops of bowel, \>6cm, haustra * _Mx_: surgery, flatus tube (in sigmoid volvulus) NOTE: 3/6/9 rule

Answer 49

Colostomy - RIF, flushed, normal faecal matter Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer * NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf) Stoma examination: * Hands around stoma and ask to cough --\> check for hernia + check for skin changes * Offer stoma rectal examination (finger into stoma)

Answer 50

**Presentation:** progressive dysphagia (solids --\> then liquids) + FLAWS **Types:** * Squamous cell carcinoma (SCC) - less common in UK, **_middle oesophagus_**, RFs: alcohol, smoking * Adenocarcinoma - most common in UK, **_lower oesophagus_**, assoc w/ _GORD_ (long-term --\> metaplasia - Barrett's oesophagus --\> eventually become dysplastic/ malignant) **Mx:** SURGICAL * **Ivor Lewis oesophagectomy** - involves _midline laparotomy_ + _right thoracotomy_ (stomach is mobilised and pushed through oesophageal hiatus) * **McKeown oesophagectomy** - as above + _left neck incision_ (oesophagus can be pulled up through neck incision)

Answer 51

* Causes: alcohol, gallstones (GET SMASHED) * Duct obstruction: _gallstones (50%),_ trauma, tumours * Metabolic/toxic: _alcohol (33%),_ drugs, hypercalcaemia/hyperlipidaemia * Ischaemia: shock * Infection/inflammation: viruses (mumps), AI * Patterns of injury: * **Periductal** – cause: duct obstruction * Necrosis of acinar cells near ducts * **Perilobular** – cause: ischaemia (shock) * Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected * **Panlobular** – develops as ½ progress * **Pathophysiology:** vicious cycle **-** activated enzymes --\> acinar necrosis --\> enzyme release * Lipase release --\> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits) * Ix: * Bloods – FBC, U&E, LFTs, CRP, Amylase * Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR * NOTE: Epigastric pain --\> remember to do rectal exam (looking for melaena) * Mx - supportive (IV fluids + analgesia first) * Resus patient (IV fluids, analgesia, antiemetic, abx) --\> ITU if glasgow score \>3 * VTE prophylaxis * Complications: * Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue --\> can be infected --\> abscess * Systemic: shock, hypoglycaemia, hypocalcaemia Severity criteria = **GLASGOW score (PANCREAS):** * **P**aO2 * **A**ge * **N**eutrophils (WBC) * **C**a * **R**enal funct (urea) * **E**nzymes (LDH) * **A**lbumin * **S**ugar (glucose)

Answer 52

**Diverticulosis:** colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet) **Diverticular disease:** above + Sx **Diverticulitis:** infection & inflammation of diverticulum * **Hinchey classification** for acute diverticulitis: 1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess \<4cm 2. Pelvic/interloop abscess/abscess \>4cm 3. Purulent peritonitis 4. Faeculent peritonitis Presentation: * RFs: \>50yrs, low dietary fibre * LIF pain, raised WCC, fever, painless rectal bleed Ix: * FBC, U&E, CRP, (BC, ABG & lactate if septic) * **_Contrast CT abdo_** (if suspected acute diverticulitis) * Other imaging: * CXR (rule out pneumoperitoneum) * Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia) * CT angiogram (if excess bleeding) Mx: * Conservative: * Increased fibre & fluids * Excercise, weight loss, stop smoking * Medical: * Fybogel - if constipated * _PO Dicycloverine_ = anti-spasmodic (for abdo cramping) * Acute diverticulitis: * Uncomplicated: oral abx (amoxicillin) * Complicated: * Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery) * Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx * Reccurent = open/laparoscopic resection

Answer 53

Bedside: urine dip Bloods: VBG, FBC, U&E, CRP, LFTs + Bone profile, Amylase, Clotting, G&S ± BC (if temp) Imaging: erect CXR, AXR * CTKUB if thinking renal stones * CTAP if collecting/perforation/obstruction * CT angiogram if ischaemia/bleeding/AAA * USS/MRCP if cholecystitis/gall stones

Answer 54

**Lobes** * **Frontal:** * Primary motor cortex (posterior frontal lobe) - initiates + regulates movement * NOTE: in motor cortex face/arms are lateral, legs are medial * Broca zone - speech production (defect --\> expressive dysphasia) * **Parietal:** * Primary somatosensory cortex (anterior parietal lobe) * **Occipital:** * Primary visual cortex (posterior occipital lobe) * Optic nerve pathways to _lateral geniculate nucleus_ --\> optic radiations through temporal and parietal lobes --\> primary visual cortex * **Temporal:** * Wernicke's zone - understanding language (defect --\> receptive dysphasia)

Answer 55

Bitemporal hemianopia = compression at _optic chiasm_ * Presentation: "I didn't notice the bus coming", "I didn't see the car when I walked across the road" --\> peripheral vision is gone * Causes: * **Craniopharyngioma** - compress from above * **Pituitary adenoma** - compress from below Quadrantonopias: * Causes: * **Superior** = _temporal_ lobe lesion * **Inferior** = _parietal_ lobe lesion * NOTE: use inverse rule - superior means that it is affecting the bottom of retina and temporal lobe is below the parietal lobe

Answer 56

Circle of Willis - perfuses brain * **Cerebral arteries** - anterior, middle, posterior (all bordering the circle) * **ACA** - supplies _anterior & medial brain_ (frontal lobe + medial motor & somatosensory cortices) --\> *behavioural changes, weakness legs \> arms, mild sensory defect* * **MCA** - supplies the _lateral brain_ (lateral motor & somatosensory cortices, language - Broca & Wernicke's, optic tracts) --\> *weakness face \> arms \> legs, aphasia (expressive/receptive), hemisensory defect, homonymous hemianopia* * **PCA** - supplies _inferior & posterior brain_ (affecting visual cortex and tracts) --\> *homonymous hemianopia, visual agnosia/prosopagnosia* * Major arteries giving rise to the circle of Willis: * **Vert****ebral artery** (from the spine) * **Internal carotid artery** (gives rise to A & M cerebral arteries)

Answer 57

Outer layers of the brain: * Skull \> dura mater (adherent to inside of skull) \> arachnoid mater \> pia mater \> brain parenchyma Types: * **Extradural** haemorrhage- bleed between dura mater & skull * Most common = skull fracture of pterion (temple) --\> trauma to **_middle meningeal artery_** * Hx: clear trauma --\> transient LoC --\> _lucid interval_ --\> ongoing headache --\> reduced consciousness * **Convex (EGG) appearance on CT-head** as blood sealed in by dura ± soft-tissue oedema outside skull (trauma site) * Mx: A-E approach, refer to neurosurgery * Monitor GCS = deterioration * **Subdural** haemorrhage - bleed between dura & arachnoid mater * Tearing of _bridging veins_ going from outer surface of brain to dura mater * Common in _elderly + alcoholics_ (both have cerebral atrophy) * Types: **both concave (SICKLE) appearance on CT-head** * Acute - assoc w/ trauma + blood _white (hyperdense)_ on CT-head * Chronic - little/no Hx of head trauma e.g. fall several weeks ago and then not been normal since (elderly) + _dark (hypodense)_ blood on CT-head * Reduced consciousness, if severe = focal neurology (esp. if midline shift) * Mx: A-E, neurosurgery referral * Monitor GCS, reverse Warfarin * **Subarachnoid** haemorrhage - between arachnoid & pia matter * Caused by an aneurysm (berry) or trauma * Presentation: sudden-onset worst headache ever, photophobia, neck stiffness * LP 12hrs after Sx-onset (xanthochromia) * Mx: A-E approach * Monitor GCS and neuro obs * Discuss with neurosurgery * Other – fluids, monitor Na, nimodipine * Complications: * Vasospasm – presents like a stroke * Hyponatraemia – can be SIADH * Rebleed - coil ASAP if possible

Answer 58

Types: * **Tension** - band-like, front of forehead, causes: dehydration, stress * **Cluster** - intense pain behind/around eye (worse @night + lacrimation & ptosis during attack), daily clusters for 4-6wks then nothing for months, M\>F * Mx: 100% O2 + nasal triptans * **Migraine** - intense/throbbing, focal, aura, photophobia * Triggers: alcohol, chocolate, cheese, oestrogens (OCP) * Mx: * Acute - simple analgesia, dark room + **_Triptans_** (take as soon as Sx start) * Prevent - trigger avoidance + **propranolol**/ **topiramate** (anticonvulsant, terratogenic) /**amitriptytline** (TCA) * **Meningitis** - generalised, moves down neck, neck stiffness + fever + rash (meningococcal) * Ix: CT-head, LP (type of meningitis), BC (causative organism) * Mx: * Suspected in primary care - **IM/IV Benzypenicillin** * Secondary care - **IV Ceftriaxone** _± Amoxicillin_ (infants/\>50yrs) * If could be encephalitis (seizure/behavioural) - _IV Aciclovir_ * **SAH** - sudden-onset, worst headache ever ± neck stiffness, can get preceding sentinel bleed (minor), assoc w/ PCKD (Berry aneurysm in Circle of Willis)/Marfan's * Ix: non-contrast CT --\> LP for xanthochromia (after 12hrs) * Mx: **_nimodipine_** (CCB, give every 4hrs, reduces vasospasm in cerebral arteries) * **Giant cell (temporal) arteritis** - vasculitis --\> scalp tenderness, jaw claudication, vision loss, assoc w/ polymyalgia rheumatica (\>50yrs) * Ix: ESR, temporal artery biopsy * Mx: **high-dose Prednisolone** (to prevent blindness, do not wait for biopsy) * **Trigeminal neuralgia** - electric shock-like pain on _touching_ face (extremely tender) * Divisions of trigeminal nerve (V2&3) * Ix: MRI brain * Mx: Carbamazepine (for pain), neurology referral * **Raised ICP** - worse at night/on waking/coughing/straining ± N&V, visual disturbances * Mx: osmotic diuresis - mannitol/hypertonic saline * **Cerebral Venous Sinus Thrombosis** (VTE in the brain) - papilloedema, 6th nerve palsy, _seizures, Cushing's reflex_ (HTN, bradycardia, Cheyne-Stokes breathing) * Ix: MRI w/ MR venography * Mx: LMWH * **Idiopathic intracranial HTN (IIH)** - Obese, female, papilloedema, postural headache worse with straining, assoc w/ OCP * Ix: visual field testing, fundoscopy, MRI brain, LP (≥25 opening pressure) * Mx: _acetazolamide_ (carbonic anhydrase inh), weight loss, LPs + VP/LP shunt, ophthalmology follow-up

Answer 59

Def: better to use cardiovascular accident (CVA) * Stroke ≥24hrs, TIA ≤24hrs Presentation: * Pyramidal weakness (flexors stronger than extensors in upper limb, opposite in lower limb), hypertonia, hyperreflexia * Hemiplegic/scissor gait --\> circumduction * TIA: _Amaurosis Fugax_ (black curtain) * If ≥2 in 1wk = high risk of stroke --\> ADMIT * Aspirin 300mg + secondary prevention (as for stroke) DDx: * Cerebral lesion - 80% ischaemic, 20% haemorrhagic (reduced GCS & raised ICP) * Neoplastic - SOL * Rare: syphilis, Todd's paralysis (post-ictal), migraine, MS, cerebral abscess, rheumatological (arteritis) Classification: **Bamford aka Oxford** * **Total anterior circulation stroke:** hemiplegia, homonymous hemianopia, higher cortical dysfunction * **Partial anterior circulation stroke:** 2/3 * **Lacunar circulation stroke:** hemi-motor OR hemi-sensory stroke only * **Posterior stroke:** cranial nerve problems, eye-movement disorder, cerebella presentation * Weber's & Wallenberg's (lateral medullary syndrome = posterior cerebellar artery infarct) **Ix:** * BEFORE Tx = **CT-head** - 80% strokes ischaemic, 20% haemorrhagic (wrong Tx will make it much worse) --\> haemorrhage has an area of hyperdense (white) bleeding * After initial Mx --\> **identify cause:** * ****Structural heart defect - _echocardiogram_ * AF - _ambulatory ECG_ (24hr tape if no obv sign of AF as outpatient) * Carotid atherosclerosis - _carotid doppler_ --\> carotid artery stenosis (70-99%) = carotid endarterectomy Mx: A-E approach + URGENTLY contact stroke team --\> dedicated stroke unit, if ischaemic: * **Immediately:** * **Aspirin 300mg** OD + _STOP_ anticoagulants (high risk of haemorrhagic transformation in first 2wks) * \<4.5hrs since Sx onset: **thrombolysis** (Alteplase = tPA) * C/I: any sign of active bleeding, very high BP, recent surgery, raised ICP * \>4.5hrs since Sx onset: conservative Mx: * BM - keep controlled \<11 (sliding scale insulin) * NG tube (nutrition) * **MDT** - dietician, SALT, PT/OT * \< 6hrs (sometimes up to 24hrs, depending on size, area, damage) --\> thrombectomy (neurosurgery) * **After 2wks:** * STOP aspirin --\> start **clopidogrel 75mg OD** + consider _anticoagulation_ (e.g. if AF) - DOAC/Warfarin * Manage vascular RFs (DM, HTN, QRISK etc.)

Answer 60

Primary motor cortex --\> **pyramidal tracts** = VOLUNTARY - include: * Corticobulbar tracts - head & neck voluntary movement * Corticospinal tracts - body voluntary movement **Extrapyramidal tracts** = INVOLUNTARY - basal ganglia, cerebellum, vestibular nucleus NOTE: pyramidal = GAS (starts movement), extrapyramidal = CLUTCH (smooths movement)

Answer 61

**Def:** a neurodegenerative disease of **dopaminergic neurones** of substantia nigra (part of basal ganglia in the midbrain) **Cardinal Sx** (from extrapyramidal involuntary dysfunction)**:** _resting tremor_, _rigidity_ (cogwheeling due to superimposed tremor), _bradykinesia, postural instability_ + insomnia, hypomimia (mask face), depression, autonomic dysfunction DDx: * Benign essential tremor - bilateral, postural, FHx, alcohol improves it (in 50%) * Drug-induced (anti-psychotic, metoclopramide) - _drug chart_ * **MSA** (multisystem atrophy) incl Shy-Drager (autonomic) - _cerebellar signs_ * **PSP** (progressive supranuclear palsy) - _loss of downward gaze_ * **LBD** (Lewy body dementia) - _visual hallucinations_ * _Normal-pressure hydrocephalus_ - gait disturbance, cognitive impairment, impaired bladder control * Other: * Corticobasal degeneration - single-arm signs, alien limb syndrome (myoclonus) * Wilson's disease (copper) - motor **Ix:** clinical Dx --\> dopaminergic agent trial ± MRI scan/DAT scan **Mx:** problem = lack of dopamine in substantia nigra --\> aim of Tx is to increase dopamine here * **Dopamine agonist** (cross BBB): * Good for younger patients to reduce time on levodopa (as get very sensitised) * Types: * **Non-ergot -** _ropinirole, pramipexole_ - avoid below SEs = 1st line but still get **dopamine dysregulation syndrome** (hypersexuality & gambling) * _SC Apomorphine_ for advanced disease * Ergot - cabergoline, bromocriptine --\> retroperitoneal/pulmonary fibrosis * '**L-DOPA (levodopa)** _AND_ **peripheral DOPA-decarboxylase enzyme (Carbidopa)**' = Sinemet/Medapar * Relevant physiology: * Substantia nigra contains dopaminergic neurones with _DOPA decarboxylase_ (converts L-DOPA --\> dopamine) - not happening as normal in Parkinson's * Peripheral DOPA-decarboxylase in body * Chemoreceptor trigger zone (CTZ) --\> triggers nausea & vomiting * Drug explanation: * If give L-DOPA by itself it will be broken down by peripheral DOPA-decarboxylase into dopamine - this can't cross BBB to reach substantia nigra but can reach CTZ --\> nausea/vomiting * Instead, give L-DOPA with peripheral DOPA-decarboxylase inhibitor to allow more L-DOPA to cross BBB to reach dopaminergic neurones in substantial nigra to be converted to dopamine (some still reaches CTZ --\> SE of nausea/vomiting) * Other SEs: dyskinesia, on-off phenomena, postural hypotension * Amantadine - for dyskinesia secondary to levodopa * COMT inhibitors e.g. entacapone for tailing off betw/ doses of levodopa Complications: * Falls, cognitive impairment, depression * Drool (SALT/glycopyrronium) * Meds SEs (e.g. vomiting)

Answer 62

**Corticospinal tract = voluntary motor pathway for body:** 1. Cortex - primary motor cortex (posterior frontal cortex) 2. Medulla - tracts from PMC converge and **cross over** = _pyramids_ 3. Spinal cord - UMN synapases with LMN 4. Peripheral nerves - LMN innervates muscle **UMN lesions** * Causes (anything affecting brain itself): stroke, SOL, MND, MS * Signs: hypertonia, hyperreflexia, spasticity (velocity/direction-dependent), upgoing plantars, pronator drift * NOTE: increased tone/reflexes as -ve feedback loop from the brain is removed **LMN lesions** * Causes (affect peripheral nerves): MND, trauma, polio, GBS * Signs: hypotonia, hyporeflexia, muscle atrophy, fasciculations, fibrillations * NOTE: reduced tone/reflexes because no nerve supply

Answer 63

**SUMMARY:** * **Normal gait cycle:** 1) heel strike 2) foot flat 3) mid stance 4) heel off 5) toe-off * **Antalgic gait** - limping due to pain e.g. osteoarthritis, inflammatory joint disease, fracture, sciatica * **Hemi/Diplegic gait** - uni/bilateral circumduction of leg - CNS lesion (bilateral is called a 'scissoring gait') * **Parkinsonian gait** - shuffling gait, no arm swing - Parkinson's/DLB/Antipsychotics * **Ataxic gait** - wide/broad-based stance & imbalance - Cerebellar/Vestibular/Sensory neuropathy * NOTE: can't do _tandem walk_ * **Neuropathic gait** - high-step gait (from foot drop) - motor neuropathy e.g. L5 radiculopathy (e.g. herniated disc), common peroneal neuropathy, MS, Charcot-Marie-Tooth disease * Can't walk on _heels_ * **Myopathic gait** - waddling/Trendelenburg gait (hip sways to one/both sides - hip abductor muscles weak) - muscular dystrophy/myopathy * **Choreiform gait** - involuntary movements - Basal ganglia disease e.g. Parkinson's meds, Huntington's, Wilson's, Cerebral Palsy * **Stomping gait** - sensory neuropathy (loss of proprioception & vibration sense = dorsal column disease) * _Vibration_ --\> _proprioception_ (Romberg's +ve) --\> _light touch_ (in order lost) * Causes: SACD (subacute combined degen cord - B12), Friedrich's ataxia, Tabes/taboparesis & tabes dorsalis (syphilis), * _Marche à petit pas_ - small steps = normal pressure hydrocephalus **IN-DEPTH:** **Normal gait cycle:** 1) heel strike 2) foot flat 3) mid stance 4) heel off 5) toe off **Antalgic gait** - _limping due to pain_ * Causes: osteoarthritis, inflammatory joint disease, lower limb fracture, nerve entrapment (sciatica) **Hemiplegic gait** - _unilateral circumduction of leg_ to prevent dragging foot * CNS lesion --\> unilateral weakness & spasticity (spastic flexion of upper limb vs extension of lower limb) * Causes - UMN lesion: * Unilateral cerebral lesion e.g. stroke, SOL, trauma, MS * Hemisection of spinal cord (trauma) **Diplegic gait** - _bilateral circumduction of legs_ (scissoring gait_)_ * CNS lesion as above but bilateral clinical findings - spasticity worse in lower limbs vs upper limbs ± hyperreflexia, clonus, Babinski +ve, reduced power, sensory level if spinal cord pathology * Causes: * Spinal cord lesion e.g. prolapsed intervertebral disc, spinal spondylosis, spinal tumour/infarct, transverse myelitis * Bilateral brain lesion - cerebral palsy, MS, bilateral brain infarcts, midline tumour (paraspinal meningioma) * MND - if also LMN findings (wasting, fasciculations) **Parkinsonian gait** - _shuffling gait_ * Loss of dopaminergic neurones in substantia nigra of basal ganglia --\> extrapyramidal dysregulation = _rigidity, bradykinesia_, resting tremor, postural instability * Features of parkinsonian gait: * Initiation - slow to start walking * Step length - _shuffling gait_ (short steps) & festinant gait (progressively smaller steps) * Arm swing - reduced (early feature) * Posture - flexed trunk & neck = _stooped_ * Turning - postural instability * Causes: Parkinson's, Dementia w/ LBs, Parkinson's plus syndromes (Multisystem atrophy & progressive supranuclear palsy), drug-induced (antipsychotics/emetics) **Ataxic gait** - _wide/broad-based stance_ (to maintain balance) * Assoc w/: * Midline _cerebellar_ disease (alcoholism/B12 def, MS, cerebellar stroke) - **DANISH** (dysdiadokokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia) * _Vestibular_ disease (labyrinthitis, Meniere's, acoustic neuroma) - vertigo, N&V * _Sensory_ ataxia (peripheral neuropathy e.g. DM) - +ve Romberg's, impaired proprioception, impaired vibration sense, lack of other cerebellar signs * Features of ataxic gaint: * Stance - broad-based ataxic gait * Stability - staggering, slow, unsteady --\> veer towards side of lesion * Turning - very difficult **Neuropathic gait** - _high-step gait (from foot drop)_ * Weakness in muscles of distal limb (foot dorsiflexors) - damage to peripheral nerves providing motor innervation --\> foot drop & dragging toes --\> knee & hip flex excessively to compensate * Other features: peripheral vascular disease, peripheral sensory impairment, reduced/absent reflexes * Causes: motor neuropathy * Isolated common peroneal nerve palsy (trauma/compression) * L5 radiculopathy (disc prolapse) * Generalised polyneuropathy involving multiple nerves (DM, MND, Charcot-Marie Tooth disease) **Myopathic gait** - _waddling/Trendelenburg_ gait (hip sways to one/both sides) * Weakness of hip abductors --\> can't stabilise pelvis --\> tilts down towards unsupported side * Assoc features: hard to stand from seat/squat/lying without arms, +ve trendelenburg's sign (stand on one leg - if the hip on the side of the raised leg drops = +ve) * Causes: muscular dystrophy, myopathy (e.g. in hyperthyroidism, Cushing's, acromegaly, Polymyalgia rheumatica) **Choreiform gait** - _involuntary movements_ * Oro-facial dyskinesia (grimacing/lip-smacking) & choreic mov of upper/lower limbs = dance-like/writhing @rest/mov * Causes: Basal ganglia disease * Huntington's, Sydenham's chorea, Cerebal palsy (Choreiform type), WIlson's disease, Dopaminergic meds (e.g. Parkinson's)

Answer 64

Def: evidence of damage to CNS that is separated in time & space Key features: * Profile: young, female (catheter & walking aid/wheelchair), eye & cerebellar signs * Initial: * Ipsilateral visual disturbance - greying/blurring ± pain on eye mov/loss of red colours * Sensory phenomena - wetness/burning, uncomfortable band around the chest * Lhermitte's sign - electric shock down neck and along spine & may radiate along limbs * Uthoff's - neuro Sx worsen with increased temperature (hoff = hot) * UMN Sx: hyperreflexia, hypertonia, pyramidal pattern (arm flexors stronger, leg extensors stronger) * Dorsal column disease - reduced vibration, proprioception, Romberg's +ve * Eyes: * Internuclear ophthalmoplegia * Adduction paralysis and abduction nystagmus * From lesion in **_medial longitudinal fasciculus_** * Optic nerve damage: * Colour & visual acuity loss, RAPD * Central scotoma (central blindspot), optic atrophy * CN palsy (most commonly 6th - as longest) * Cerebellar signs (imbalance, can't tandem walk) DDx: * Cervical spondylosis - wo/ UMN signs but no cerebellar signs * Subacute combined degeneration of the cord (SACD) - dorsal columns & cerebellar - if low B12 * Neuromyelitis optica aka Devic's disease (IgG against aquaporin-4 channel) - optic neuritis & transverse myelitis but no cerebellar Sx Clinical courses/patterns: * **Relapsing-remitting** - steady decline + strong flair * Primary progressive - steady decline without attacks * Secondary progressive - initial relapsing-remitting becoming primary progressive * Marburg variant - very severe, rapidly progressive Ix: * Bedside: * Fundoscopy (optic neuritis), full functional assessment (physio, OT) * Nerve conduction studies - visual evoked potentials (VEPs) - if single nerve lesion, delayed response * Bloods - B12 (SACD), TFTs * Imaging: * MRI (T2) head (lesions disseminated in time & space) - **McDonald's criteria** * Periventricular white matter lesions * LP: IgG oligoclonal bands, high protein Mx: * **Acute relapse:** _high-dose methylprednisolone_ (shortens acute attack) e.g. optic neuritis (painful eye mov + reduced visual acuity) * **Long-term -** MDT approach (physio, OT, SALT) * Mobility - mobility aids, physio, OT * Spasticity --\> Baclofen/Gabapentin (Dantrolene if CKD) * Bowel (laxatives) & bladder (oxybutynin, LT catheter) * Fatigue --\> Amantadine * Oscillopsia (visual jumping when actually still) --\> Gabapentin * Emotional lability --\> Amitriptyline Poor prognostic features: * Brainstem/cerebellar disease at onset * \>40yrs at onset * Primary progressive MS (no resolution

Answer 65

Def: Acute presentation of thiamine (B1) def Triad: confusion, ataxia, nystagmus Complication = Korsakoff syndrome (chronic & permanent memory problems) Delirium tremens: confusion, _visual hallucinations_, tachycardia, pyrexia

Answer 66

ALL: involve MDT for full functional assessment (physio & OT) UMN: * Imaging (brain ± spinal cord) * CSF (LP) * Brain biopsy LMN: * Nerve conduction studies & electromyography (NCS & EMG) * Bloods (metabolic, abs) * Muscle/nerve biopsy

Answer 67

Presentation: mixed UMN/LMN (no sensory deficits, no eye involvement) * UMN in lower limbs (spasticity, hyperreflexia, upgoing plantars) * LMN in upper limbs (hypotonia, hyporeflexia, _fasciculations_, wasting) * Bulbar/pseudo-bulbar tongue/speech (**tongue fasciculations**, palatal paralysis, nasal speech) * NORMAL SENSORY EXAM DDx mixed signs: * Dual pathology (stroke + peripheral neuropathy) * Conus medullaris lesion - painful, assoc with traumatic spinal injury/higher up mets) * B12 def (subacute combined degen of spinal cord) = cofactor in myelination (as is folate) Types: * **Amyotrophic lateral sclerosis** (60%) - classic (UMN & LMN) * Progressive Bulbar Palsy (30%) - CN 9-12 --\> dysarthria (speech), dysphagia (swallowing) * Primary Lateral Sclerosis - pure UMN onset * Progressive Muscular Atrophy - pure LMN onset, 'flail limb' appearance Dx: clinical, exclude other causes * EMG/NCS (nerve conduction study) - chronic nerve root denervation * Imaging - MRI (cervical, thoracic, lumbar spine) - exclude other causes Mx: no cure - MDT approach * Conservative - SALT (swallowing), physio & OT * Sx-control: * Quinine - muscle cramp * Anticholinergics e.g. hyoscine patches - drooling * Exercise & nutrition * Prognostic: * Riluzole - glutamate antagonist (extend life expectancy by 3-5 months) * NIV - if respiratory muscles no longer functioning Complications: resp compromise, frontal lobe dementia (2%)

Answer 68

Rigidity (in Parkinson's disease) = increased muscle tone, that is _not_ velocity or direction-dependent * In Parkinson's get Cogwheeling = rigidity overlayed by tremor Spasticity (in Stroke) = increased muscle tone, that is _velocity or direction-dependent_ * Flexors/extensors become imbalanced in strength - certain directions have increased muscle tone (not all) AND worse stiffness if move arm more quickly

Answer 69

Def: compression of Cauda Equina (nerve fibres below L1-2) Sx: **can you feel it while you urinate/when you tug on catheter?** * Severe back pain * Saddle anaesthesia (numb around the anus) * Bladder/bowel dysfunction (urinary retention, faecal incontinence) * Lower limb weakness * Reduced anal tone (on PR exam) Causes: _large disc herniation_, cancer, trauma, abscess, haematoma * NOTE: if likely mets e.g. background of prostate cancer --\> 16mg Dexamethasone (reduces swelling) Ix: urgent MRI scan (+ PR exam) Mx: * In normal disc herniation (above cauda equina): * Get the patient to keep moving (or muscles will seize up) * Analgesia - PR Diclofenac (neuropathic pain) + Diazepam * In cauda equina --\> _urgent referral to neurosurgery for decompression/laminectomy_

Answer 70

**Types:** * **Alzheimer's disease** * Progressive decline in cognitive function * Tx: _Acetylcholinesterase inhibitors_ (Donepezil)/NMDA receptor antagonists (Memantine) * **Vascular dementia** * A stepwise decline in cognitive function * Background of vascular disease (IHD, PVD) * **Dementia with Lewy Bodies** * Triad - _dementia, hallucinations, parkinsonism_ * Balance - Parkinsonism = dopamine def vs hallucinations = dopamine excess * **Frontotemporal** - personality changes, early onset * **Depressive pseudodementia** - disinterested, low mood

Answer 71

1. SWIFT - scars, wasting, involuntary mov, fasciculations, tremors 2. Screens: * Upper - hands out pronate (tremor?), supine hands and close eyes (_pronator drift_ = UMN lesion) * Lower: * Stand up from chair with hands crossed (prox power) * Gait assessment - normal, only on heels/toes (distal power), tandem walk (balance) * Stand with both feet together (balance) --\> _Romberg's test_ if they could do prior (eyes closed - proprioception). 3. Tone: * "Clasp-knife spasticity" = pyramidal (UMN) lesion - velocity/direction-dependent e.g. stroke/spinal cord compression/MND * _CLONUS_ also present in UMN lesion * Rigidity = extrapyramidal lesion - velocity/direction _independent_, types: * "Lead-pipe" = NMS (anti-psychotics) * "Cogwheeling" = Parkinson's (tremor on rigidity) 4. Check power against gravity - raise arms/legs (if so MRC is 3+) 5. Eliciting reflexes: * Biceps - thumb over cubital fossa (from lateral side) while they move hand towards shoulder (should be central) - place nail over tendon and hit nail. Get patient to rest hand on knee * Brachioradialis - first 2 fingers 1/3 up arm from wrist, lateral arm. Get patient to rest hand on knee * Triceps - hold out patient arm at 90 degrees takin the weight of the patient's arm, stand behind patient, hit just above the olecranon * Knee jerk - if patient supine, support behind knee * Ankle jerk - if patient supine, cross one leg over the other, dorsiflex foot, strike ankle tendon OR keep straight, dorsiflex foot and strike ball of the foot (just below ball under toes) 6. Jendrassik maneuver - clench hands together/clench jaw at the same time as eliciting reflex 7. Put finger just beyond reach so they have to stretch

Answer 72

Nerve innovations: * S1,2 - buckle my shoe - ankle jerk (Achilles tendon) * L3,4 - kick the door - knee jerk (patellar tendon) * C5,6 - pick up sticks - biceps, brachioradialis reflex * C7,8 - lay them straight - triceps reflex

Answer 73

Meningitis: * Presentation: headache, fever, photophobia, neck stiffness * Causes: * Bacterial – **N. meningitides, S. pneumo** (TB; neonates/elderly – GBS/Listeria/E.coli) – Listeria also more common in _alcoholics_ * Viral – enterovirus (Coxsackie, echovirus), mumps, HSV2 * Fungal – cryptococcus neoformans (chr) * Ix: A-E, **BC**, CT head, **LP** (CT first, if raised ICP --\> LP would cause coning) * Kernig sign - flex knee & hip to 90 degrees --\> extend knee (painful & limited extension) * Brudzinski sign - raise head while flat --\> hip & knee flexion * Mx: bacterial – **IV ceftriaxone** ± amoxicillin (Listeria - neonate/elderly) * **IM BenPen** for possible meningococcal infection (rash) in GP setting before sending to the hospital * Viral – supportive (self-limiting) * Altered consciousness (encephalitis?) --\> add _IV acyclovir_ Encephalitis: * Presentation: headache, fever, seizures, drowsiness, confusion (viral _HSV1_ affects temporal lobes --\> affecting consciousness) * Ix: BC, CT head, LP * Mx: **IV acyclovir** ± anti-convulsants

Answer 74

Dark matter middle (cell bodies = synapses) --\> white matter on the outside (neurone tracts) Sensory pathways (ascending - goes up): * **_Dorsal columns_** (posterior) - **fine touch, vibration, proprioception** * Sensory receptors - _1st order neurone_ up spinal column along ipsilateral side * At the **medulla oblongata** - synapses with _2nd order neurone_ that crosses the midline (decussation) * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * **_Spinothalamic tracts_** (anterior) - **pain & temperature** * **Nociceptors** (pain) - _1st order neurone_ to **Substantia Gelatinosa** within grey matter of spinal cord * Synapses with _2nd order neurone_ & immediately crosses midline (decussation) to ascend spinothalamic tract * *NOTE: spinothalamic tracts decussate at the level the neurone enters the spinal cord* * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * (Spinocerebellar tracts (lateral) - proprioceptive info to cerebellum) Motor pathways (descending - goes down): * **_Corticospinal tracts_** (anterior = trunk, neck, shoulders; lateral - limbs) - **voluntary motor control** (from primary motor cortex) * From the **Primary Motor Cortex** - _UMN_ goes to the **Medulla** and crosses over (decussation) * At the **anterior horn** for each spinal level synapses with _LMN_--\> muscle * NOTE: at any spinal level will be LMNs exiting the spine and UMNs that travel down further before synapsing with their respective LMN * SO *cord pathology above the level of Cauda Equina --\> some UMN & LMN signs*

Answer 75

Def: tendency to have recurrent, unprovoked seizures * Seizure = episodes of abnormal uncoordinated excessive brain activity * Provoked seizures = consequence of inf/drugs * Unprovoked = epilepsy Types: * **Generalised** (whole brain): * Tonic-clonic, Tonic, Atonic, Myoclonic --\> Tx: _Na Valproate_ (AVOID in girls/women of childbearing age) * Absence --\> Tx: _Ethosuximide_/Na Valproate * **Focal** - aware (conscious) OR impaired awareness (impaired consciousness) * Tx: _Lamotrigine_ Status epilepticus = \>5mins/repeated seizures without full recovery in between * 1st - IV lorazepam 4mg --\> repeat * 2nd - phenytoin infusion * 3rd - general anaesthesia * If no IV access --\> rectal diazepam/buccal midazolam

Answer 76

* 1 flicker * 2 is moves with gravity removed * **3 is movement against gravity** * 4 is reduced power against resistance * 5 is normal

Answer 77

How to describe: * **Eyes disconjugate in the primary position** * Comment on the direction of globe e.g. down & out * **Where is the diplopia worst? When has the outside image disappeared?** Cover each eye in turn & the _outer image will disappear_ when eye with palsy is covered * What is the reaction to light? NOTE: **LR6 SO4** **3rd nerve palsy** (oculomotor) --\> _down & out gaze_ * All the extraocular muscles not working except 4 & 6 so LR turns eye out, SO turns eye down & out + _ptosis & diplopia_ (to the left) * Causes: * **Medial** (internal infarct) = _pupil-sparing_ (PS fibres intact) * Mononeuritis multiplex (microvascular causes) - HTN, DM * **Surgical** (external compression) = _pupil dilation_ (PS fibres damaged as on periphery of 3rd nerve trunk) * PCA Aneurysm (posterior communicating artery at junction with internal carotid artery), tumour, dissection * PCAA = painful * SOL/haemorrhage in 3rd nerve nucleus --\> bilateral ptosis * Mx: check BP & BM, _examine for 4th nerve palsy_ (check for cavernous sinus problem) * Dilated pupil - **_CT scan & angiography_** (esp if painful) * Medical palsy = self-resolve within 3 months - prism glasses (minimise double vision) * Ask to look down - if 4th nerve intact --\> _mov of scleral blood vessels_ (as eye tries to turn inwards) = subtle * NOTE: 3rd & 4th nerve palsy (± V1 (ophthalmic), 6th nerve) = **_cavernous sinus involvemen_****_t_** (tumour/thrombosis/aneurysm) **4th nerve palsy** (trochlear) - subtle _up & in gaze_ + head tilt away from affected eye * SO not functioning so upward deviation of the eye (opposite of 3rd nerve palsy) --\> unable to depress eye in adduction (have problems when walking down stairs/reading book) * Causes: **head trauma** e.g. whiplash/concussion; mononeuritis multiplex (microvascular e.g. DM, HTN), congenital * NOTE: see above about 3rd & 4th nerve palsy **6th nerve palsy** (abducens) - _medial gaze_ (can't look laterally) = VERY IMPORTANT TO PICK UP * LR not functioning so medial deviation of the eye * Causes: * Most common: microvascular (HTN, DM) * **Raised ICP** (tumour/aneurysm), demyelination/mass/vascular * _'false localising sign'_ - can't identify what side of the brain is affected as *6th nerve has the longest IC _nerve root_ in the brain* (+ one of first nerves to be affected) * NOTE: vagus nerve is the longest overall CN * Mx: * Examine other CNs (7th, 8th) & cerebellar system (cerebellar pontine angle lesion) * Fundoscopy - papilloedema (raised ICP) **7th nerve palsy** (facial): * Presentation: * Bell's phenomenon (when asked to close eyes they can't shut eyelids and eyes will roll back) * Loss of taste anterior 2/3 tongue, mouth droop, smooth nasolabial folds, hyperacusis (one ear louder than other as stapedius muscle supplied by facial nerve --\> dampens sound normally --\> louder sound) * UMN vs LMN (UMN spares forehead) * Causes: * **Viral/idiopathic** * Damaged facial nerve - trauma (e.g. forceps delivery) * Inf - HZV (Ramsay-Hunt = vesicles in-ear canal), otitis media * Compression/mass - parotid tumour/cerebellar-pontine angle (CPA) lesion * MUST get ENT to rule out cholesteatoma & acoustic neuroma = _MRI brain scan_ * Mx: 50% LMN (Bell's palsy) recover spontaneously in 6 months * Eye drops + eye patch * \<72hrs --\> steroids * Long-term consequences: * **Synkinesis of facial muscles** (when nerve regenerates --\> innervate wrong muscles e.g. when scrunch eyes lip twitches upwards) * Crocodile tears phenomena - where wrongly innervates lacrimal gland = cry when smiling

Answer 78

Def: acute, sudden-onset, unilateral facial palsy of probable viral aetiology Presentation: **URTI --\> unilateral facial palsy** (all branches, no-forehead sparing) **with pain behind the ear & dry eye** * Bell's sign: failure of eye closure (dryness and conjunctivitis) * Precipitating factors (e.g., dental extraction, upper respiratory tract infection) * Single episode (recurrence = likely alternative Dx) * Unilateral (bilateral = likely alternative Dx e.g. Lyme disease, GBS, sarcoidosis, leukaemia) * Involves all nerve branches (originates proximal to the geniculate ganglion so should be equal distribution) * No constitutional Sx (would indicate Lyme disease, AI, granulomatous disease) * Keratoconjunctiva sicca (dry eye - from inadequate blinking) * Pain behind the ear Ix: clinical Dx (Dx of exclusion) * Electroneurography (ENoG, 72hrs-14 days after palsy starts) * Needle electromyography (\>90% degeneration in CMAP) * Serology for Borrelia burgdorferi (if recent visit to Lyme disease-endemic region) Mx: * Pred (if \<72hrs Sx onset) * Eye protection (to prevent keratoconjunctivitis sicca progressing to exposure keratopathy) * Severe palsy/complete paralysis --\> concurrent antiviral therapy (aciclovir), surgical decompression * Prognosis = 75% make a full recovery

Answer 79

Def: The sensation of movement between person & environment: spinning sensation, N&V Vertigo Hx: * Vertigo (sense of motion) vs light-headed vs pre-syncope * Assoc hearing loss? If yes = not BPPV * Meniere's disease - vertigo, tinnitus, hearing loss --\> no driving * Viral labyrinthitis - following URTI * Tx: * Vertigo - prochlorperazine (reg for 3 days) * Tinnitus - betahistine Detailed breakdown: * Peripheral cause: * **BPPV** - crystals displaced in SCC * sudden, brief, episodic, only on certain head _movement_ * Ix: **Dix-hallpike test** to confirm (up-beat torsional nystagmus) * Mx: * Education & reassurance (remission from 3wks - 6 months) * Epley manoeuvre * Betahistine (for vertigo) * **Meniere's disease** - excessive endolymph in SCC * Clustered attacks \<12hrs: _Fluctuating hearing loss_, tinnitus, vertigo lasts minutes- hours (more than one episode) * Ix: * +ve Romberg's test * Pure-tone & speech audiometry * Tympanometry * Otoacoustic emissions (OAE) * Mx: dietary changes + lifestyle modification (limit salt, caffeine, alcohol/smoking, stress) ± thiazide diuretic (triamterene/hydrochlorothiazide)/acetazolamide * Vertigo - _betahistine_ * Tinnitus - devices * Hearing loss - CS * **Labyrinthitis** - inflammation of otic capsule caused by viruses/bacteria affecting inner ear (cochlear & vestibular system) * Severe vertigo, nystagmus and vomiting following an URTI * Bacterial - severe hearing loss (irreversible) * Viral - less severe Sx (often reversible) * Ix: cranial nerve exam (Renne's, Weber's), audiometry (sensorineural hearing loss) * Mx: * If severe: IV prochlorperazine * If less severe: PO cyclizine and prochlorperazine * Tx cause e.g. bacterial * Ongoing - vestibular rebab (physio, OT) * NOTE: **vestibular neuronitis** is inflammation of the vestibular nerve = the same presentation without the hearing loss (normal audiogram) - comes on acutely but can take weeks to settle * Ix & Mx - as above * Central cause: * Stroke/TIA - lateral medullary syndrome (Wallenberg syndrome), cerebellar infarct/haemorrhage * Cerebellar stroke - _headache_ (occipital sudden & prominent), _N&V_, _ataxia_ (imbalance) * **Acoustic neuroma (vestibular schwannoma)** - benign cerebellopontine angle tumour * Unilateral sensorineural hearing loss, facial numbness, progressive intermittent unsteadiness * Can have co-existing _neurofibromatosis type 2_ * Ix: audiometry, (CT head (can be missed if small)) --\> gadolinium-enhanced MRI (absence of dural tail) * Mx: * Vestibular migraine - headache, photophobia, phonophobia, aura * Vertebrobasilar ischaemia - reduced flow to posterior circulation of brain * Head position provokes vertigo * Hemifacial numbness & contralateral peripheral weakness/paraesthesia ± arm claudication (from subclavian steal) * MS

Answer 80

Ix: * Bloods (metabolic, abs), CT --\> LP ± MRI spine (exclude other causes) * Nerve conduction studies Mx: ADMIT suspected cases - normally self-limiting course * MDT - psychologist, SALT (if speech muscles affected) * Plasmapheresis (plasma exchange) * High-dose IVIG * DVT prophylaxis

Answer 81

C3,4,5 keep the diaphragm alive Phrenic nerve

Answer 82

**Upper limb:** * Pronator drift (palms up) * Power - stabilise joint, chicken, boxer, arms out straight, , separate fingers separate + hold paper, thumb straight up in air (abduction) * Reflexes - nerve innovations: * Biceps/brachioradialis - C5/6 - pick up sticks * Brachioradialis - feel for radial tubercle then go several cm lower * Triceps - C7/8 - lay them straight * Coordination - finger-nose test (put elbow out like chicken) & dysdiadokokinesia * Sensation - dorsal column: "does this feel _normal_?" * Fine-touch - glove & stocking or dermatomal: * C5 - deltoid area * C6 - thumb * C7 - middle finger * C8 - little finger * T1 - medial forearm * T2 - medial upper arm * Vibration - 128Hz tuning fork (IPJ thumb, hit on elbow to trigger, ask patient to say yes when it stops) * Proprioception (hold either side of thumb) * Sensation - spinothalamic: * Pain - neurotip * Temperature - prongs of tuning fork (sternum then dorsum of hand) * Sensation pathology: * Radiculopathy (dermatome - nerve root) * Glove & stocking - peripheral neuropathy e.g. DM

Answer 83

Lower limb: * Gait & Romberg's test * Tone - clonus * Power - stabilise joint (contralateral-side if hip) * Nerve innovations of reflexes: * Knee - L3/4 - kick the door * Ankle - S1/2 - in the shoe * Babinski reflex * Coordination = heel-shin test * Sensation - dorsal column: * Fine-touch - glove & stocking or dermatomal: "does this feel _normal_?" * (L1 - higher upper inner thigh) * L2 - upper inner thigh * L3 - medial just above knee * L4 - medial upper calf * L5 - lateral calf * S1 - plantar aspect of the foot (sole) * Vibration - 128Hz tuning fork (IPJ big toe, hit on elbow to trigger, ask patient to say yes when it stops) * Proprioception (hold either side of big toe) * Sensation - spinothalamic: * Pain - neurotip * Temperature - prongs of tuning fork (sternum then dorsum of foot) * Sensation pathology: * Radiculopathy (dermatome - nerve root) * Glove & stocking - peripheral neuropathy e.g. DM

Answer 84

Ix: _MRI whole spine_ (often multifocal lesions) Mx: * 1st line = **surgical decompression** (if localised, fit enough) * 2nd line = radiotherapy (external beam radiotherapy)

Answer 85

Thunderclap headache - SAH

Answer 86

Cause: Reactivation of the varicella-zoster virus in the genticulate ganglion of CNVII Presentation: * Otalgia * Facial nerve palsy * Vesicular rash around ear * Vertigo + tinnitus Mx: * Valaciclovir PO * Steroids PO * NOTE: If treated within 72 hours, 75% recover, otherwise only 1/3 fully recover

Answer 87

**Cerebellar** signs _ipsilateral_ **Motor nerves** travel laterally in brainstem & cross @medulla **Dorsal columns** are _posterior_ & cross @medulla **Spinothalamic tract** is _anterior_ in spinal cord & cross in spinal cord Localisation: * **Cortical** - UMN pyramidal signs (hypertonia, hyperreflexia, babinski) * **Basal ganglia** - rigidity, tremor, bradykinesia * **Cerebellar** - DANISH * **Nerve root** (dermatome/myotome)/single nerve - LMN signs (hypotonia, hyporeflexia, fasciculations, wasting, sensory loss)

Answer 88

**Myasthenia Gravis** * Def: * Chr AI disorder of post-synaptic membrane of NMJ in skeletal muscle * _Abs to AChR_ on post-synaptic membrane * Presentation: * **_Muscle fatiguability incl dysphagia_**, rarely SoB * **Eyes** - _bilateral ptosis_ (and compensatory increased frontalis muscle activity = raised eyebrows), diplopia * Face - dysarthria (slurred speech), facial paresis * _Curtain sign_ - when raising one upper eyelid the other one drops down * Assoc: **thymomas** (in the chest) * Ix: * Abs: **AChR** (on post-synaptic membrane), MUSK abs * Serial pul funct tests (FVC & negative inspiratory force) * NOTE: do not wait for ABG findings - late in course * CT-chest (for thymoma) * Mx: * **Acetylcholinesterase inhibitors** (Pyridostigmine) + IS (azathioprine) * IVIG/Plasmapheresis * Surgery - thymectomy * **Myasthenic crisis** = acute respiratory failure - FVC \<1L, negative inspiratory force (NIF) ≤20cm H2O, need mechanical ventilatory support * Accessory muscle use indicates sign inspiratory muscle weakness * Weak cough indicates sign expiratory muscle weakness * ABG often shows hypercapnia before hypoxia * Low threshold for endotracheal intubation (rapid deterioration of bulbar & resp muscles) * Mx: _intubation + mechanical ventilation_ (& Mx above) **Lambert-Eaton Myasthenic Syndrome (LEMS)** * Def: rare AI disorder of NMJ * Pre-synaptic membrane _Ab to voltage-gated Ca-channel_ receptors * 40% occur as paraneoplastic disorder assoc w/ SCLC * Presentation: * Limb weakness - proximal legs --\> proximal arms e.g. waddling gait * **STRONGER WITH USE** (vs MG get's weaker with use) * Hyporeflexia, NO eye involvement (compared to MG) * Autonomic disturbance - **_dry mouth_** (& orthostatic hypotension, sweating, GI & urinary problems, visual blurring, sexual dysfunction) * Associated with: _small cell lung cancer (SCLC)_ * Ix: * Nerve conduction studies, EMG, serial PFTs * Ab testing (Voltage-gated Ca-channels & AChR-abs) * CT chest (SCLC) * Mx: MDT support * Tx underlying cause, Amifampridine * IVIg/plasma exchange * Supportive care

Answer 89

Normal CSF opening pressure ≤25 Dx: Cerebral Venous Sinus Thrombosis (VTE in the brain) * DDx = Idiopathic intracranial HTN - but would not make you this unstable neurologically * Obese, female, papilloedema, postural headache worse with straining, assoc w/ OCP * Ix: visual field testing, fundoscopy, MRI brain, LP (≥25 opening pressure) * Mx: acetazolamide, weight loss, LPs + VP/LP shunt, ophthalmology follow-up Presentation: headache, papilloedema, signs of raised ICP (6th nerve palsy), seizures, Cushing's reflex (HTN, bradycardia, irregular breathing = Cheyne-Stokes) Ix: MRI w/ MR venography Mx: LMWH

Answer 90

Presentation * Disc herniation - acute unilateral radiculopathy (pain & numb in specific dermatome/weakness in muscle group) * Straight leg raise +ve * Spinal stenosis - insidious neurogenic claudication (intermittent back pain worse on walking/standing) ± pain radiating down leg/leg paraesthesia * RFs: rev back injury/surgery, manual labour Ix: * Disc herniation - erect lumbar x-ray & MRI spine * Spinal stenosis - plane x-ray, MRI (T2-weighted) Mx: surgical decompression

Answer 91

**_LMN_** presentation = muscle pathology * Face: * Myopathic facies (sunken cheeks, bilateral ptosis, expressionless) * Wasting of facial & muscles of mastication * Frontotemporal balding * Distal wasting, weakness w/ loss of ankle jerks * Associations: cataracts, dysphagia, cardiac (cardiomyopathy, heart block), DM, hypogonadism (gynaecomastia/testicular atrophy) * Exam - failure of immediate relaxation after voluntary contraction * _Percussion myotonia_ - tap thenar eminence and thumb contracts * Slow-releasing grip - SHAKE HANDS (or make a fist and then spread fingers quickly or squeeze eyes shut and open quickly) Ix: * Conservative: _full functional assessment_ (incl. SALT), lung function tests (NM resp insufficiency), ECG/echo (CMO/HB), slit lamp (cataracts) * Bloods - BM (DM assoc), _CK_, genetic testing * Imaging & invasive: * Electromyography (EMG) - 'dive-bomber' potentials * Muscle/nerve biopsy Mx: MDT approach * Phenytoin for myotonia, weakness has no Tx * Genetic counselling - AD w/ genetic anticipation (trinucleotide repeat - worse severity/earlier presentation with each generation) * Avoid _statins_ (can cause myopathy)

Answer 92

Hammertoes - bilateral, symmetrical, distal wasting of small muscles of feet * Advanced = dorsal guttering from distal wasting, wasting of _extensor digitorum brevis at inferior border of lateral malleolus_ * Similar can be seen in the hands = wasting of _first dorsal interosseus_ Sign of **Charcot-Marie-Tooth disease** aka hereditary motor & sensory neuropathy (HMSN)/peroneal muscular atrophy (PMA) * Hx ankle sprains & scoliosis * Motor & sensory losses (sensory milder) = classic peripheral neuropathy * LMN pattern of weakness: * Motor loss in anterolateral compartments of legs (ankle dorsiflexion & toe extension) * Absent reflexes (plantar reflexes show no response) * Sensory loss in _glove & stocking distribution_ bilaterally * Pes cavus ± palpable common peroneal nerve, thickened nerves @medial malleolus * High stepping (foot drop) & ataxic gait * Test for foot drop = _heel walking_ What do I need to check for? NO scars over fibula (would indicate peroneal nerve damage from trauma e.g. car accident) DDx: * _Common peroneal nerve palsy_ (inversion of foot normal) * Sensory peripheral neuropathy: B12-def (SACD), Alcohol, DM, Hypothyroid (vitiligo?), HIV, drugs * Motor peripheral neuropathy: lead poisoning Types: * **Type 1** - demyelination, AD * Type 2 - axonal, AD/AR * Type 3 - demyelination, AR & presents as infant Ix: full functional assessment, FHx, _nerve conduction studies_, genetic testing Mx: * Physio, walking aids with ankle & foot supports (e.g. foot splint)

Answer 93

Hand muscle wasting - _dorsal guttering_ = first to be affected in ulnar lesions * First dorsal interosseous (next to thumb) = ulnar nerve * Abductor policies brevis (thenar eminence) = median nerve * Weakness of both - suspect T1 radiculopathy * NOTE: ulnar nerve innervates most of the intrinsic muscles of hand except median nerve serves **LOAF**: 2 radial **L**umbricals, **O**pponenes pollicis, **A**bductor pollicis brevis & **F**lexor pollicis brevis **Ulnar nerve palsy** = _claw hand_ @rest (4th & 5th fingers in extension at MCP, flexion at PIP/DIP) * Commonest site of lesion = elbow (arthritis @wrist & elbow) * Froment's sign (weak adductor pollicis brevis --\> thumb flexion) = +ve if thumb arches to hold paper = _ulnar nerve palsy_ * **Ulnar paradox** - higher lesion causes lesser deformity as lower lesions spares flexor digitorum profundus (causes flexion at DIP) **Median nerve palsy** = _sign of benediction_ on asking to close hand (thumb, index finger can't close, middle finger can close partially) * Look for sensation over thenar eminence --\> if lost can't be carpal tunnel syndrome (still median nerve palsy but arises proximally to carpal tunnel) * Bilateral carpal tunnel syndrome causes: Acromegaly, Amyloid (periorbital purpura after sneezing), DM, Hypothyroid, pregnancy

Answer 94

Sx: confusion, altered GCS, headaches, seizures, encephalopathic Ix: fluid status, U&E, paired osmolalities (urine, serum) **Fluid status:** * **HYPO**volaemic (dehydrated) - _WASTING_ (diarrhoea/vomiting, diuretics) --\> **IV fluids** * **EU**volaemic (normal) - _ENDOCRINE_ (SIADH, hypothyroidism, Addison's) --\> **fluid restrict + Tx underlying cause** * **HYPER**volaemic (fluid overload) - _FAILURE_ (liver, renal, heart) --\> **fluid restrict + Tx underlying cause** **Urine Na:** * \<20 mmol/L --\> hypovolaemia (increased Na reabsorption in kidneys --\> increasing H20 retention --\> reducing urine Na) * \>20 mmol/L --\> SIADH (BUT if on diuretics, urine Na can't be interpreted) --\> fluid restrict Na corrected too fast (\>10) = osmotic demyelination syndrome (central pontine myelinolysis) --\> pseudo-bulbar palsy, paraparesis, locked-in syndrome

Answer 95

Areas involved: 1. Dietary intake 2. Absorption in GI tract 3. Adrenals & kidneys - regulate serum K concentration **_HYPO_**kalaemia: * Poor dietary intake, vomiting/diarrhoea * Diuretics - loop/thiazide (block channels causing K reabsorption) * Hyperadrenalism (Conn's, bilateral adrenal hyperplasia, Cushing's) * Conn's/BAH - excess aldosterone - NOTE: Aldosterone promotes reabsorption Na, _excretion K_ * Cushing's = excess cortisol --\> off-target effect on mineralocorticoid receptors --\> mimics aldosterone **_HYPER_**kalaemia: * false = HAEMOLYSIS --\> repeat sample * Kidney failure e.g. on dialysis (kidneys = main route to remove K) * Anti-HTN/diuretics * ACEi/ARB - reduce kidney hyperfiltration, mainly a risk if CKD * K⁺-sparing diuretics e.g. spironolactone/amiloride * Addison's disease (failure - can't produce enough cortisol/aldosterone) * NOTE: appearance on ECG = **tented T-waves**, broad QRS, prolonged PR interval **Hyperkalaemia Tx:** * **Protect heart** - **IV 10-30ml _10% Ca Gluconate_** (repeat /15m, x5 MAX) * **Reduce K⁺:** * 1st line - **_10U Actrapid_** (insulin \> drive K into cells) **AND _100mL 20% glucose_** (to prevent hypo) * 2nd line - 5mg Salbutamol NEB (b-agonist) * **Ix cause:** drug chart, U&E (kidney funct), short SynACTHen test (Addison's)

Answer 96

**Hormone production:** * **Parathyroid gland** - PTH --\> _INCREASE Ca_: * Bone resorption * GI absorption * Kidney - decreased excretion, increases 1alpha-hydroxylation (vitD activation) * Vit D₃aka cholecalciferol (UV)/ergocalciferol (diet) * In **Liver** --\> 25-OH(D) aka calcidiol * In **Kidney** + _1alpha-hydroxylase_ --\> 1,25-OH₂(D) aka Calcitriol (activated vitD) --\> _INCREASE Ca_ * GI absorption * Kidney - decreased excretion **HYPERcalcemia** * **Sx:** * Stones - urinary tract calculi * Bones - fractures * (Abdo) moans - dyspepsia * Thrones - polyuria, constipation * (Psych) overtones - depression, psychosis * Ix - check **_PTH_**: * **Low** - _hypercalcemia of malignancy_ (PTH axis is functioning normally) - bone mets, PTHrP (released by lung SCC), myeloma (CRAB) * **Normal/high** - _primary hyperparathyroidism_ (as if serum Ca high, PTH should be low) - adenoma, hyperplasia, MEN 1&2 * Other: * Fluid status, ECG (short QT), protein electrophoresis, 24hr urinary Ca (familial hypocalciuric hypercalcemia) * Bloods - bone profile (Ca, PO4), U&E * Imaging: CXR * Mx: * IMMEDIATE = **aggressive IV 0.9% fluid resus** (4-6L over 24krs), repeat Ca * Tx underlying cause: * Parathyroid adenoma - minimally invasive surgery (subtotal/total parathyroidectomy) * Malig - **Zalendronate**/Pamidronate (inhibit osteoclast activity), slow infusion * Other: * If bone mets --\> _bisphosphonates_ * If renal failure --\> Cinacalcet (reduce PTH) * Recheck serum Ca @day 2 --\> 4 **HYPOcalcaemia** * Causes: * Hypoparathyroidism (PO4 high, PTH low) * Pseudohypoparathyroidism (PO4 high, PTH high) = PTH resistance * CKD (high PO4, PTH high, ALP high) * Vit D def (rickets/osteomalacia, low/normal PO4, high PTH, high ALP) * Hypomagnesaemia (low/normal PO4, low/normal PTH, normal ALP) * Presentation: * Peri-oral numbness, digital paraesthesia, dermatitis * +ve _Trousseau's_ (BP cuff 20 over SBP for 3mins --\> salt bae hand), _Chovstek signs_ (tap over the masseter muscle in the inferior pre-auricular area) * Laryngospasm (wheeze, dysphagia, muscle cramps) * Confusion, seizures, prolonged QT * Ix: serum Ca, PO4, Mg, PTH, U&E, Vit D * Mx: PO/IV replacement of Ca

Answer 97

Presentation: polyuria, polydipsia, dehydration * Ketosis - malaise, vomiting * FHx, other endo disorders * If known DM: * Previous DM control (hyp/hyper) * Micro/macrovascular complications * Diabetic eye disease (Dx & Tx) RFs: overweight, FHx (DM), PMHx (GDM), PCOS, HTN, dyslipidemia, CVD Criteria for Dx (repeat test needed for Dx): * Fasting plasma glucose of ≥7.0 (normal ≤6) * OGTT (BM 2hours after 75g glucose-load)/ Sx + random plasma glucose of ≥11.1mmol/l (normal \<7.8) * HbA1c ≥48mmol/mol (≥6.5%) - not for young/T1DM, acutely ill, haem disease, preg, iatrogenic T1DM Mx: **_exogenous insulin_** to avoid DKA & long-term complications * Diet - lower fat, higher carbs = counting carbs (adjust insulin around diet rather than limiting eating) * Diabetic specialist nurse - EDUCATE: * Self-adjust dose - **_D_**AFNE course for T1DM (*D for DM*) * Fingerprick glucose * Calorie intake & carb counting * Phone support * Don't stop insulin during acute illness, maintain calorie intake * Insulin regimens: * 1st line - **Basal-bolus regimen** * Basal (background) - BD insulin detemir (or Levemir/Lantus/Tresiba) as basal insulin * Bolus (before meals) - analogue rapid-acting insulin e.g. insulin Lispro (Humalog)/Aspart (Novorapid)/Neutral (Actrapid) * Other: * BD biphasic (premixed insulin, hypos common) e.g. Novomix, Humulin M3, Humalog Mix * OD before bed long-acting (for T2DM) * NOTE: intermediate-acting insulin e.g. Humulin I, Insulatard T2DM Mx: * 1st line - Lifestyle changes - **_D_**ESMOND course for T2DM (*D for DM*), dietician input, self-BM monitoring (individual HbA1c target \<6.5) * HbA1c targets: * No hypoglycaemics - 48mmol/mol * Hypoglycaemics - 53mmol/mol * Escalate Tx - 58mmol/mol * Medication: * 2nd - **Metformin** (SEs: diarrhoea, LA - avoid if eGFR \<30) * 3rd - ADD **Sulphonylurea e.g. Gliclazide** (SEs: hypoglycaemia, weight gain) * 4th - ADD other DM med: * **Pioglitazone** (SEs: hypoglycaemia, weight gain, oedema, fractures in elderly) * C/I in HF, bladder cancer * **SGLT-2 inhibitor e.g. Empagliflozin** (SEs: Hypoglycaemia, weight loss, UTI) * Not recommended in impaired renal funct * **DPP-4 inhibitor e.g. Linagliptin** (APPROVED FOR USE IN **_CKD_**, weight neutral) * **GLP-1 analogues e.g. Exenatide/Liraglutide** (SE: weight loss - useful if BMI \>35; vomiting) * Not recommended in impaired renal funct * 5th - If on triple therapy & not providing control --\> commence **_insulin_** * CVD risk Mx - anti-HTN, anti-lipid, QRISK-3 score * Diabetic nephropathy Mx: * **Monitor albumin-creatinine ratio (ACR)** * Consider _ACEi/ARB_ early * Diabetic neuropathy Mx: * Annual Sx review (erectile dysfunction, autonomic neuropathy - orthostatic hypotension, gastroparesis, bladder emptying difficulties) * Annual foot screen + specialist foot Mx, monitor for diabetic foot/ulcers ± amputation * Diabetic retinopathy: retinal screen annually (age ≥12yrs) * Background: need to tighten control * Venodilation, microaneurysms (dots), hard exudates (lipid deposits) * Tx: tighten glycaemic control, refer if near macula * Pre-proliferative (mild) - _soft exudates_ (cotton wool spots e.g. infarcts) * Proliferative - _neovascularization_ (+ floaters, reduced acuity) * Tx: **pan-retinal photocoagulation** * Diabetic maculopathy - hard exudates, oedema (+ blurred vision, reduced acuity) * Tx: **intravitreal triamcinolone acetonide** decreases macula oedema * NOTE: Pre-diabetic --\> refer to diabetes prevention programme (DPP) Diabetes complications: * Microvascular: * Eye - diabetic retinopathy (± cataracts, glaucoma) * Kidney - diabetic nephropathy * Neuropathy - damage to PNS --\> diabetic neuropathy (peripheral neuropathy - glove & stockings distribution) --\> diabetic ulcers/gangrene * Macrovascular: * Brain - stroke/TIA/cog impairment * Heart - coronary heart disease * Extremities - PVD, diabetic ulcers/gangrene

Answer 98

Insulin: * High level of insulin --\> reduces serum BM (pushes into surrounding tissues & hepatic glucose store) * Low level of insulin --\> switches off ketone production Pathophysiology: * HHS = complication of T2DM * In HHS have enough insulin to switch of ketone production but not enough to reduce BM lvls * High glucose - osmotically active --\> polyuria --\> dehydration HHS criteria: * Hypovolaemia * Glucose \>30mmol/L * NO ketonaemia * Serum osmolality \>320mOsmol/kg Mx: REHYDRATE = **IV 0.9% NaCl (3-6L by 12hrs, deficit 110-220mL/kg)** * Targets: * Reduce **Na** by less than _10mmol/L/day_ (otherwise risk osmotic demyelination syndrome) * Reduce **BM** by over _5mmol/L/hr_ * NOTE: if targets not met by 0.9% saline --\> 0.45% instead * If fluid alone are not enough --\> **0.05 units/kg/hr fixed-rate insulin infusion**

Answer 99

Causes: * **Hypovolaemia** (H20 loss \> Na loss) - most common * **GI loss:** D&V * **Skin loss:** excessive sweating, burns * **Renal loss:** _diabetes insipidus_ (DI), osmotic diuresis (glucose/mannitol), loop diuretics, kidney disease * Euovolaemia - Resp (tachypnoea), skin (sweating, fever), renal (DI) * Hypervolaemia * Mineralocorticoid excess – _Conn’s syndrome_ * Inappropriate saline Causes thirst --\> most people self-correct UNLESS: **failure to ingest water** (Elderly/dementia, fasting (e.g., for surgery), excess loss) Mx: SLOW Hartmann’s (rapid correction --\> **cerebral oedema)**

Answer 100

**Sx:** hypernatremia (lethargy, thirst, irritable, confusion, coma, fits), polyuria, urine plasma osmolality \<2 (very dilute) **Types:** * Central (lack of ADH prod in hypothalamus) – pituitary surgery, irradiation, trauma, infarction * Nephrogenic (resistance to ADH effects) – hypercalcaemia, hypokalaemia, meds (lithium) **Ix:** rule out DDx (BM, review drugs, K/Ca lvls) * U&E, Ca, BM, serum & urine osmolarities * Dx: 2-step fluid deprivation test = give **desmopressin (DDAVP):** * Normal/primary polydipsia --\> urine concentrates on fluid deprivation (\>600) * Cranial DI - giving desmopressin allows ADH prod --\> urine conc * Nephrogenic DI: urine never concentrates * NOTE: DI excluded if urine to plasma (U: P) osmolarity ratio \>2:1 * Cranial MRI - if suspect cranial DI NOTE: Fluid deprivation test process: * Baseline urine osmolality * Fluid deprivation for 8hrs, take urine osmolality * Give desmopressin, wait 8hrs, take urine osmolality Tx: * Nephrogenic DI --\> fluids (+ monitor UO) + **thiazide diuretics** (hydrochlorothiazide - weird/does not make sense) * Central DI --\> fluids + **desmopressin**

Answer 101

**Causes:** * _Spurious sample_ * **Excessive intake:** oral, parenteral, stored blood transfusion * **Transcellular mov** (ICF\>ECF): * Acidosis, insulin shortage (DKA - high glucose, high ketones, metabolic acidosis) * Tissue damage/catabolic state (rhabdomyolysis) – CK very high * **Decreased excretion:** * AKI (oliguric phase)/CKD (late) * Drugs (spironolactone – K-sparing diuretic, ACEi/ARB/NSAID) * Addison’s (mineralocorticoid def) **Ix:** * Repeat sample (VBG to also look for acidosis) * CK, Creatinine & Urea * AM Cortisol/Short synACTHen test * **_ECG_** * Loss of p-waves, tall, tented T-waves, broad QRS (+ bradycardia) * If severe & untreated --\> ECG forms ‘sine wave’ **Mx** (if \>5.5 w/ ECG changes OR \>6.5): * **IV 10mls 10% calcium gluconate** (cardioprotective, doesn’t lower K) * If on Digoxin – IV Ca causes arrhythmias – cardiac monitoring * **IV 10ml 20% dextrose + 10 units short-acting insulin** e.g., Actrapid (insulin drives K into cells, dextrose prevents hypo) * **Neb salbutamol** adjunct + treat cause

Answer 102

**Hypothyroidism:** * Causes: * _Primary:_ * **Hashimoto's thyroiditis** - most common hypothyroidism * Goitre, AI disease (vitiligo, pernicious anaemia, T1DM, Addison's) * Elderly females * May be initial ‘Hashitoxicosis’ * +++ Autoantibody titres * _Antithyroid peroxidase (TPO) & antithyroglobulin (TG)_ * **Atrophic AI thyroiditis** * No goitre, anti-TPO/TSH * Iodine def, meds (carbimazole, lithium), thyroid surgery * _Secondary:_ pituitary gland fails to produce TSH * Tumour, vascular (Sheehan syndrome), radiation, inf * Ix: * Bedside: ECG (pericardial effusion, ischaemia) * Bloods: FBC, U&E, TFTs, Lipids, Prolactin, Anti-TPO/TG * Imaging: CXR (effusions, HF) * Mx: thyroid replacement therapy (levothyroxine) * Monitor with serum TSH, careful with dose in elderly (prone to IHD) * Myxoedema coma - A-E & active warming, T3 slow IV, hydrocortisone IV * Associated complications: * Cardiac - HF * Serous effusions (pleural, peritoneal, pericardial, joint) * Neuro - carpal tunnel, proximal myopathy, cerebellar dysfunction, myxedema coma * Systemic - dyslipidemia, anaemia **Hyperthyroidism:** * Presentation: * Weight loss, increased appetite * Heat intolerance, tremor, sweating, palpitations * Mood (anxious, irritable) * Bowel habit (diarrhoea), menses (oligomenorrhoea) * Goitre * Eye Sx (watering, gritty, red) * Other AI disease (vitiligo) * Signs: * Lid lag (eyes) * Palmar erythema * Brisk reflexes * Sinus tachy/AF * Ix: TSH low, T3/4 high, TPO (may be raised), anti-TSHr ab (in Graves), technetium 99m uptake scan (diffuse/reduced) * Causes: * High-uptake: * **Graves’ disease**: MOST COMMON, autoantibodies ++ (_anti-TSH-R ab_), * Eye signs: proptosis --\> exophthalmos, diplopia, visual loss * Peripheral signs: pretibial myxoedema, thyroid acropatchy, onycholysis, bruit over thyroid * **Toxic multinodular goitre aka Plummer's disease:** hot nodules, _painless_ * Toxic adenoma: 5%, single ‘hot nodule’ on isotope scan (1 area of uptake) * Low-uptake: * **Subacute De Quervains (viral) thyroiditis**: self-limiting post-viral painful goiter. Initially hyperthyroid, then hypothyroid * Tx: NSAIDs * Postpartum thyroiditis (like De Quervain’s but postpartum) * Mx: * Conservative: lifestyle changes, corneal lubricants * **Medical:** * Sx relief – _B-blockers_ * Antithyroid meds - _Carbimazole_ (or propylthiouracil) * SEs: rashes, agranulocytosis - monitor * _Radioiodine:_ * acts slowly, effective, best Tx for toxic multinodular goitre * Risk of permanent hypothyroidism (10%) * CI in preg/lactating women * **Surgical:** _subtotal thyroidectomy_ (in large goitre/relapse) * Monitoring with TFTs annually * **Thyroid storm:** acute state of shock, pyrexia, confusion, vomiting * HDU/ITU support * _Propylthiouracil_ 600mg --\> 200mg QDS * Stable iodine (Lugol's iodine) ≥1hr later * Propranolol, dexamethasone & IV fluids

Answer 103

**Cushing's** #HighCortisol * Causes: * ACTH-dependent: * **_Pituitary_ tumour** (85%) = “Cushing’s disease” * _Ectopic_ ACTH-prod tumour (5%) - SCLC/carcinoid tumour * ACTH-independent: * _Adrenal_ tumour (10%) * _Iatrogenic_ steroid use * Presentation: * Thin skin, easy bruising, proximal myopathy, obesity (moon face, buffalo hump), other (hirsutism, acne) * Exam: vertical abdo striae * HTN, DM, osteoporosis (back/bone pain) * Ix: * Exclude pseudo-Cushing's - depression, alcohol excess, chr inf (no muscle weakness) * Confirm Dx: **low-dose dex suppression test** - fail to suppress cortisol in all * Overnight dexamethasone suppression test (1g @11pm) OR * 48hr low-dose 0.5mg/6h PO dexamethasone supression test OR * 24-hr urinary free cortisol (test x3 as low sensitivity) * **Plasma ACTH measured**: * High - _CRH test_ identifies if pituitary or ectopic * Could also do bilateral inferior petrosal sinus sampling --\> if no mass --\> CT contrast CAP for ectopic * Low - adrenal tumour --\> _CT/MRI adrenal glands_ --\> if nothing --\> adrenal vein sampling * Mx: treat underlying disease e.g. _withhold steroids_ or surgical removal of the lesion * Cushing's disease (pituitary tumour) --\> **trans-sphenoidal hypophysectomy** (complications - DI, hypopituitarism) * 2nd - _pituitary radiotherapy_ (also used if still high cortisol post-surgery) --\> progressive anterior pituitary failure * Metyrapone & ketoconazole - sometimes before/after surgery * 3rd - laparoscopic bilateral adrenalectomy in refractory (but require lifelong glucocorticoid/mineralocorticoid replacement + risk of Nelson's syndrome (increased skin pigment from high ACTH **Hypoadrenalism** * Causes: * AI: **Addison's disease** (\>70%) * Malig: **mets** (lung, breast. kidney) * Inf: **TB** (\>10%), HIV (CMV adrenalitis), Fungal * Infiltration: granulomatous disease, hemochromatosis, amyloidosis * Iatrogenic: ketoconazole, rifampicin, phenytoin, bilateral adrenalectomy * Congenital: congenital adrenal hyperplasia (late-onset) * Presentation: * Anorexia/weight loss, fatigue/weakness, postural dizziness, reduced libido, sweating * N&V, diarrhoea, salt craving * Signs: hyperpigmentation in skin creases/lip/mouth, vitiligo, sparse axillary/pubic hair * Ix: * Bedside - postural hypotension, IGRA (TB inf) * Bloods - FBC, **U&E** (↑ K⁺, ↓ Na⁺), **low glucose**, serum Ca, AI/auto-ab screen, plasma renin & aldosterone, **short snACTHen 250mcg IM test** (not Addison's if 30min cortisol _rises \>550nmol/L_ * Imaging: CXR (past TB), adrenal CT (for TB/mets) * Mx: * Addisonina crisis: Tx underlying cause, ICU input & alert bracelet * Ppt factors: inf, trauma, surgery, missed steroid doses * Ix: _Cortisol, ACTH_, U&E * Mx: **IV hydrocortisone + IV fluids ± fludrocortisone (if primary adrenal lesion)** * Monitor BM ± IV dextrose * Bloods, urine, sputum culture ± abx * Chronic: hydrocortisone + fludrocortisone (Na homeostasis), _education_ (compliance, increase steroid dose if ppt factors, follow-up **Hyperaldosteronism** (incl. Conn's) * Primary (HTN, ↑ Na+ ↓ K+): * **Conn's -** aldosterone-secreting adrenal adenoma * _Bilateral adrenal hyperplasia_ * Secondary - decreased renal perfusion (high renin --\> Na reabsorption --\> HTN) - RAS, HF, liver failure * Ix: **aldosterone-renin ratio** (ARR), CT/MRI adrenals, adrenal vein sampling * Conn's is very high (high aldosterone, low renin) VS BAH has both high (high aldosterone, high renin) * Mx: spironolactone, unilateral adrenalectomy (for Conn's) ****_PH_**aeochromocytoma** #HighCatecholamines * Cause: adrenal medulla tumour --\>↑ catecholamines (adrenaline/NA) * Presentation: episodic headache, sweating, tachycardia, hypertension, arrhythmias, death if untreated * 10% exta-adrenal, 10% bilateral, 10% malignant * Ix: ECG (LVF, increased ST seg, VT), **24hr urinary metanephrines**, abdo CT/MRI * Mx: specialist endo centre - alpha blockade = **_PH_**enoxybenzamine then beta-blockade --\> then surgery when BP controlled (after 4-6wks)

Answer 104

DDx: * Anaemia - PUD, altered bowel habit? occult blood loss? * Thyroid disease - thyroiditis? * DM - polyuria, polydipsia, weight loss * Adrenal insufficiency * Primary hyperparathyroidism - constipation, urinary stones, abdo pain, depression * Hypopituitarism * Anxiety & depression - sleep disturbances, poor appetite, recent stress Ix: * FBC, U&E, LFTs, CRP, bone profile, HbA1c, TFTs, haematinics * CXR

Answer 105

**Normal glucose transport:** diet --\> blood --insulin--\> hepatic glucose store --GH, Cortisol, Adrenaline, Glucagon--\> blood * During starvating - GH, Cortisol, Adrenaline, Glucagon make sure there is enough glucose in the blood BUT liver also produces ketones * Ketones can cross BBB providing an alternative source of fuel for the brain when low glucose * Pancreatic beta cells --\> insulin prod --\> reduces glucose (high glucose has--\> feedback on pancreatic beta cells --\> produce more insulin) * High insulin (associated with high glucose) --\> -ve feedback on ketone prod **In insulin deficiency** - high glucose but unable to produce insulin + no -ve feedback on ketone prod --\> _high glucose, high ketones_ * High glucose - osmotically active (moves along concentration gradient into urine --\> pulling more water with it) --\> POLYURIA --\> DEHYDRATION * High ketones - acidic (metabolic acidosis) --\> enzyme dysfunction --\> COMA & DEATH DKA Ix: * Bedside - urine dip, ECG, continuous cardiac monitoring * Bloods - VBG, FBC, U&E, BC, BM * Imaging - possibly CXR DKA Dx: * BM: ≥11mmol/L * Ketones: ≥3mmol/L (serum) OR ≥2+ (urine) * Acidaemia: pH \<7.3 OR Bicarb \<15mmol (ketoacidosis) DKA Mx: A-E assessment * **IV FLUIDS** (rehydrate) * Bolus --\> 1L over 1hr --\> 2hr --\> 3hr --\> 4hr * Add _40mmol KCL_ to fluids after bolus * **0.1 U/kg/hr fixed-rate INSULIN** **infusion** (reduce ketones) * If BM \<14 --\> start _125ml/hr 10% dextrose_ * Insulin infusion continues until ketones normalise (not BM) * NOTE: follow local trust guidelines for DKA Tx as varies slightly between trusts Monitor - BM, ketones, VBG (K conc) * Hourly targets: * Fall in BM ≥3 * Fall in ketones ≥0.5 * Rise in HCO3 ≥3 * Continue until: blood ketones \<0.6, pH \>7.3, HCO3 \>18

Answer 106

Cause: macroadenoma in anterior pituitary Presentation: coarse facial features * Skin (acanthosis nigricans - thick & dark in creases), sweating, carpal tunnel syndrome (bilateral) * Arthropathy, sleep apnoea, reduced sexual functioning, visual field defects (bitemporal hemianopia) * Assoc: DM, HTN, MEN type 1 (15%) Ix: * Bedside: CN VI palsy, urine dip (glucose), ECG (cardiomyopathy) * Bloods: **elevated IGF-1**, GH lvl during OGTT (not suppressed in acromegaly) * Imaging: MRI brain (macroadenoma), sleep studies, colonoscopy (screening), visual field testing (driving) Mx: * Transsphenoidal hypophysectomy (curative) * Medical: somatostatin analogue (octreotide) * External pituitary radiotherapy (long-term 5-10yrs) Complications: * General: HTN, DM, carpal tunnel syndrome, sleep apnoea, colorectal cancer, LVH/cardiomyopathy/IHD * Anterior pituitary hypofunction: hypogonadism * Local compressive: bitemporal hemianopia

Answer 107

* Conservative measures * Medical (none proven to provide sustainable weight loss) * Orlistat (gut lipase inhibitor, SEs: profound flatus, diarrhoea) * Surgical – bariatric surgery (BMI \>40 OR \>35 w/ comorbidity assoc w/ obesity) * Needs extensive screening + commitment to long-term follow-up

Answer 108

Causes: * Prolactinoma (macroprolactinoma \>6000) * Adenoma (non-funct pituitary adenoma 1000-5000, from compression & DA lvls) * DA antagonist (metoclopramide, anti-psychotics, methyldopa) * Hypothyroidism (increased TRH stimulates prolactin prod) * Physiological (pregnancy, breastfeeding) Presentation: irreg periods, decreased libido, galactorrhoea * Bilateral hemianopia Ix: * Bedside - pregnancy test, visual fields assessment * Bloods - serum prolactin, TFTs, U&E * Imaging - pituitary MRI Mx: * Asymptomatic pre-menopausal/post-menopausal with microadenoma - observation * Symptomatic pre-menopausal/macroadenoma post-menopausal/male: * **Dopamine agonist** (Cabergoline/Bromocriptine), 2nd line - COCP (not if want pregnancy) * Trans-sphenoidal surgery (if visual Sx/pressure effects refractory to medical Tx) * Follow-up: monitor prolactin, check visual fields

Answer 109

DDx: * Thyrotoxicosis - heat intolerance, palpitations, SoB, mood (irritable/anxious), bowel habit, menses, goitre, exophthalmos, recent pregnancy * GI-related conditions (IBD, upper GI pathology, coeliac disease, chr pancreatitis) - dysphagia, vomiting, regurgitation, abdo pain, altered bowel habit * Eating disorders (Anorexia nervosa) - reduced eating, compulsive exercise * Systemic conditions (malignancy) - FLAWS Ix: * FBC, U&E, CRP, LFTs, fasting BM, bone profile, TFTs, anti-TTG, IgA levels, haematinics * CXR

Answer 110

Intro - WIPE (wash, intro, pain & position, explain) Look * General - **RASS** (Redness, Asymmetry, Swelling, Scars) * Tops: * Bones: * OA - Heberden's nodes (DIP), Bouchard's nodes (PIP) * RA - swan neck deformity, boutonniere's deformity, Z-shaped thumb, ulnar deviation, MCP palmar subluxation * Skin - scars, thinning, rashes, bruising (steroids) * Muscle - wasting * Nails - psoriatic changes (pitting, onycholysis), clubbing, nailfold vasculitis * Palms - thenar (thumb-side), hypothenar muscle wasting, palmar erythema (RA), carpal tunnel release scar, swellings (e.g. ganglions) * Extensor surfaces - psoriasis, rheumatoid nodules, gouty tophi (white uric acid crystals under the skin - fingers/elbows) Feel * TST (Temperature, Swelling, Tenderness) * Palms: * **Bulk** of thenar/hypothenar prominences * **Tendon thickening** - flexor tendon sheaths (hypertrophy/contraction --\> Dupytren's) * Flex each finger individually and then feel the tendon base as extend (trigger digit) * Tops: * **Temp** - forearm, wrist, MCP * **Squeeze joints** & feel for bony swelling, effusion, synovitis, deformity * Distal radio-ulnar joint + radial & ulnar styloid * Anatomical snuffbox (tender = scaphoid fracture) * Carpals (bimanual palpation) * MCP (squeeze along row then bimanual palpation if pain elicited) * Base of thumb (squaring = OA) * IP joints (bimanual palpation of each - nodes = OA) * **Tendon tenderness** * Around radial styloid (1st extensor compartment) = de Quervain's tenosynovitis * Around ulnar styloid = extensor carpi ulnaris tendinitis Move (active \> passive - feel for crepitus, get a few more degrees) * **Wrist movements** - active (**prayer sign & reverse prayer sign**) & passive (feel for crepitus) * **Finger movements** - make **fist** (tendon, small joint involvement), straighten fully (against gravity - joint disease, extensor tendon rupture, neuro damage) * **Thumb movements** - abduction (away from hand upward), adduction (thumb to palm), flexion (thumb to little finger) extension (lateral away from hand), opposition (thumb and little finger) Functional: * Power grip = Grip fingers * Pincer grip on finger * Ask about writing with pen, button-up shirt Brief neuro hand exam: * Motor (against resistance): * Radial (extensor forearm) - **wrist extension** * Ulnar (some of flexor forearm + hand) - **finger abduction** * Median (flexor forearm + thumb) - **thumb abduction** * Sensory: * Ulnar (up to halfway through ring finger dorsum/palm) - _hypothenar eminence_ * Median (rest of the palm + fingertip to PIP dorsal index, middle and half of the ring finger) - _thenar eminence_ * Radial (dorsum of hand excluding above) - dorsal base of the _thumb_ Special tests * **Phalen's test** - reverse prayer sign \>1 min (pain/paraesthesia = Carpal tunnel syndrome) * **Tinel's test** - median nerve at its course in the wrist - tap (paraesthesia = Carpal tunnel syndrome) * **Finkelstein's test** - hand closed around thumb + ulnar deviation (pain = de Quervain's tenosynovitis) To complete exam * Examine the elbow, full neurovascular exam DDx: degenerative, infective, inflammatory, traumatic, congenital Ix: AP & lateral views (2 views) + imaging of joints above and below as well Hand/wrist pathology: * RA - chr AI disorder --\> symmetrical deforming polyarthropathy * Synovitis, bony deformities, palmar erythema, small muscle wasting, reduced RoM, tendon rupture/subluxation * DIP joints sparred * Mx: NSAIDs, steroids, DMARDs (methotrexate), surgery * OA - mechanical joint degradation w/ degen of articular cartilage, periarticular bone remodelling & inflammation * Signs: joint crepitus, limited RoM, bony deformities * Mx: analgesia, CS injection, physio/splints, surgery * Carpal tunnel syndrome - median nerve entrapment neuropathy from compression of the median nerve in carpal tunnel * Intermittent paraesthesia, pain/burning & numb thumb, first, middle fingers and radial half of ring finger * Worse @night * Signs: loss of power + wasting of thenar eminence, sensory loss in median nerve distribution * Mx: splints, CS inj, carpal tunnel decompression * Trigger finger - thickening of flexor tendon sheath causing entrapment at A1 pulley * Discomfort/bump at base of digit and catching/clicking during extension * Mx: splints, NSAIDs, CS inj, surgical release Hand muscles anatomy: * **Median nerve** - LOAF (all thumb muscles except adductor pollicis) * **L**ateral 2 lumbricals * **O**pponens _pollicis_ * **A**bductor _pollicis_ brevis * **Fl**exor _pollicis_ brevis * **Ulnar nerve** (extrinsic hand muscles except most of thumb) * Adductor pollicis * Lumbricals (flex MCP, extend IP) * **P**almar interossei (**AD**duct fingers) = PAD * **D**orsal interossei (**AB**duct fingers) = DAB * **Radial nerve** = extensors

Answer 111

Intro - WIPE (wash, intro, pain & position, explain) Function - Gait (Antalgic, waddling = abductor dysfunction) Look: * General - RASS (Redness, Asymmetry, Swelling, Scars) * Standing up - front (quads wasting, knee swelling), side (fixed flexion deformity, foot arches), back (varus/valgus deformity, baker's cyst) * Lying on bed - scars (TKR, arthroscopic ports on either side), wasting, deformity Feel: * TST (Temperature, Swelling, Tenderness) * Effusion: * Patellar tap (push down thigh & hold, press down on patella with middle finger) * Sweep test (push down thigh, back of hand sweeps up medial x3, other back of hand sweeps down lateral, +ve is swelling on the medial side) * Palpation: * Leg straight - quadriceps tendon, medial & lateral borders of patella, patella tendon * Knee @90 degrees: * Patella tendon, tibial tuberosity (down from tendon), medial joint margin * Lateral joint margin, head of the fibula (slightly lateral and distal to knee), collateral ligaments (hands around upper calf) Move (active \> passive - feel for crepitus, get a few more degrees) * Knee extension: * Active = push knee down into bed * Passive = lift entire leg up @ ankle (hyperextension \>10 degrees) * Knee flexion: * Active = bring heel towards bum (posterior sag?) then straighten * Passive = same mov, leave knee flexed (for next part) Special tests = **3C**s of knees – **C**artilage (McMurray’s), **C**ollaterals, **C**ruciates – Lachman’s, A/P-drawer) * Anterior & posterior drawer (ant- bring towards = ACL; post - push away = PCL) * Lachman's test (flex knee to 30 degrees, right hand pulls, left hand stabilises the femur, checks ACL) * Collateral ligament assessment: * Varus stress test (LCL) - put the knee in varus positon while palpating the lateral knee joint line * Valgus stress test (MCL) - put the knee in valgus position while palpating the medial knee joint line * Menisci assessment - McMurray's test - say "would consider doing but may be too painful for the patient" * Passively flex the knee, hold the right foot with right hand apply external pressure with the left hand palpating the knee (abducting at the hip) while fixating and external rotating with the right hand, slowly extend at the knee watching for a click/discomfort = medial meniscus tear * Opposite movements to test for lateral meniscus tear To complete exam: * Assess NV status * Examine joints below and above (hip and ankle) * Further imaging if indicated (X-ray) Presentation: * Normal gait, no obvious deformities of either knee, on palpation there was no pain and there was a full range of active and passive movement * There was no evidence of laxity in the knee ligaments bilaterally DDx: degenerative, infective, inflammatory, traumatic, congenital Ix: AP & lateral views (2 views) + imaging of joints above and below as well Common pathologies: * ACL tear - twisting injury, 'pop' swelling within 1 hour, very painful for 2wks * Increased laxity on anterior drawer test/Lachman's test * Mx: physio/surgical reconstruction (if ongoing instability) * PCL tear - high energy trauma (multi-ligament knee injury/hip dislocation/fracture) * Increased laxity on posterior drawer test * Mx: physio/surgical reconstruction * Meniscal tear - twisting injury, swelling after a few hrs, sharp localised medial/lateral pain worse on hyperflexion/twisting, knee may lock/give way * Tender over medial/lateral joint line, good RoM unless knee locked, +ve McMurray's * Mx: MRI/arthroscopy to confirm, tear usually excised arthroscopically * Collateral ligament tear * Varus/valgus laxity, effusion, tenderness over affected ligaments * Mx: rest, physio, hinged brace * OA - pain & stiffness, reduced RoM, crepitus * Prepatellar bursitis - localised swelling over patella, precipitated by period of kneeling * Signs: tender over patella, normal RoM * Mx: rest, NSAIDs, aspiration/CS inj

Answer 112

Intro - WIPE (wash, intro, pain & position, explain) Function - **Gait** (Antalgic, Trendelenburg - waddling = abductor dysfunction) Look * General - RASS (Redness, Asymmetry, Swelling, Scars) * Standing inspection: * Front (pelvic tilt, quads wasting), side (lumbar lordosis, knee flexion, foot arches), behind (scoliosis, gluteal atrophy, iliac crest alignment) * **Trendelenburg's test:** * Place hand resting lightly above both hips * Bend one knee - if the hip dips on the bent side = contralateral abductor muscle weakness * Lying inspection: compare symmetry & rotation (shortened & externally rotated = fractured NoF), hip scars, dressings, skin changes Feel - check for pain, start on the normal side * TST (Temperature, Swelling, Tenderness) * Bony landmark tenderness: * Feel around hip joint (tenderness, warmth, effusion) * Feel along greater trochanter (lateral edge of thigh - trochanteric bursitis) run a hand up to greater trochanter (trochanteric bursitis) * Feel ASIS --\> pubic rami * Measure true/apparent leg lengths: * Apparent = umbilicus to medial malleolus (unequal = spinal/pelvic deformity e.g. scoliosis) * True = ASIS to ipsilateral medial malleolus (unequal = true limb shortening e.g. fracture) Move (active \> passive - feel for crepitus, get a few more degrees) * Roll side to side * Flexion: * Active (as far as can) then passive feeling for crepitus * Passive internal & external rotation (while knee is bent to 90 degrees, lose IR early in OA) * Passive abduction & adduction - place a hand on the contralateral pelvic crest to detect mov (crossing over leg for adduction) * Passive extension - lie face down, scars/muscle wasting? place hand on pelvis/lumbar spine to detect mov Special tests * **Thomas's test** (not if hip replacement --\> dislocation): * Place a hand under the lumbar spine (check no lumbar lordosis) * Flex hip on one side (knee bent) * If contralateral thigh forced off the ground = _fixed flexion deformity_ (of the side forced off the ground) * NOTE: _need to flex hip on the opposite side to that examining_ To complete exam - examine shoulder and knee, full neurovascular exam distal to joint Presentation: * Normal gait, no obvious deformities on inspection * On palpation, there was no pain with a _full range of passive and active movement_ and no fixed flexion deformity and no abductor muscle weakness DDx: degenerative, infective, inflammatory, traumatic, congenital Ix: AP & lateral views (2 views) + imaging of joints above and below as well Mx (for OA): * Conservative – physio, exercise, weight loss * Medical – analgesia, IA CS injection * Surgical – arthroplasty Common pathology: * **Hip OA** - pain, crepitus, reduced ROM (internal rotation lost first) * Hip fracture - shortened and externally rotated limb * Hip dislocation - shortened and internally rotated limb * Abductor muscle weakness - Trendelenburg's positive * Trochanteric bursitis - pain over the greater trochanter * Childhood - dislocation, Perthes, SUFE

Answer 113

Def: AI process causing **synovial joint inflammation (synovitis)** with destruction of peri-articular structures Presentation: joint pain @rest, swelling & stiffness in morning * Exam: * Symmetrical swelling w/ DIP sparing * Muscle wasting, ulnar deviation, volar subluxation @MCPs * Swan-neck & Boutonnieres’ & Z-thumb deformities * NOTE: if nail changes/extensor rash = psoriatic arthritis * Extra-articular manifestations of RA = **NO HIVE**: * **N**odules - rheumatoid nodules (25%) * **O**steoporosis (worse by steroids & immobilisation) * **H**eart & **H**aem - pericarditis, anaemia, Felty's syndrome (RA + splenomegaly + neutropenia) * **I**nterstitial: * _Pul fibrosis_ (& pleural effusions, Caplan's syndrome - nodules from RA + pneumoconiosis) * Interstitial nephritis (nephrotic syndrome) * **V**asculitis (high titre RF) * _Peripheral neuropathy_ presenting as mono-neuritis multiplex * Other neuro: _carpal tunnel_, cervical myelopathy * Splinter haemorrhages, cutaneous ulcers, distal gangrene * **E**ye pathologies - _secondary sjogren's syndrome_ (dry eyes, mouth & cough), episcleritis Ix: anti-RF/CCP, ESR/CRP, X-rays Mx: * Create an end target e.g., remission * 1st - Monotherapy with conventional DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved * Target met? * Yes = keep drug regime + lifestyle changes (stay active, healthy diet, weight loss if appropriate, alcohol/smoking) * No = titrate cDMARD/trial alternative cDMARD ± dual therapy * Target met? * Yes = keep drug regime + lifestyle changes * No = biological agents if DAS28 score \>5.1 (severe burden of disease)

Answer 114

Pathogenesis - loss of cartilage + bone remodelling --\> inflammation & osteophytes Presentation: pain worse with activity, crepitus + reduced RoM * Hands - DIP & PIP swelling = Heberden’s (DIP) & Bouchard’s nodules (PIP) * Common site = base of the thumb (1st carpometacarpal joint) * Weight-bearing joints affected e.g. knees * NOTE: midline knee scar = total knee replacement --\> fixed flexion deformity post-replacement Ix: XR (2 views e.g. AP & lateral) * LOSS: **L**oss of joint space, **O**steophytes, **S**ubchondral sclerosis, **S**ubchondral cysts Mx: * Conservative – physio, exercise, weight loss * Medical: * Analgesia (paracetamol --\> topical NSAID --\> oral NSAID/opioid) * IA CS injection * Surgical – arthroplasty (e.g. TJR)

Answer 115

Signs: * Extensor plaques with scales (scalp + behind ears) * Nails - pitting, hyperkeratosis, onycholysis * Other forms: guttate (drop-like), Koebner phenomenon Types: * Mono/oligoarthritis * Spondylitis (back) * Asymmetrical polyarthritis (incl DIP-specific) * Arthritis mutilans * Rheumatoid-like Criteria name: **CASPAR** criteria - established inflame arthritis/enthesitis + ≥3 of options Mx: * Conservative: * Psoriasis - precipitant avoidance (alcohol, smoking, stress, B-blockers) * Exercise & physio for arthritis * Medical: * Psoriasis: * Topical Tx: * Topical steroids (hydrocortisone 2.5%/betamethasone 0.05%) * Calcipotriol * PUVA = Psoralen + UVA phototherapy * Arthritis = Methotrexate, anti-TNFs

Answer 116

0 to -2.5 DEXA: * Conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes * Repeat DEXA @2yrs -2.5 * 1st line - Bisphosphonates PO (e.g. alendronic acid) --\> if not tolerate can trial Denosumab/Raloxifene/Teriparatide * Vit D + Ca replacement (if inadequate sunlight/intake exposure) * Review Tx every 3-5yrs NOTE: * If premature menopause --\> discuss HRT * If on high-dose CS (≥7.5mg OD for ≥3 months) --\> consider bisphosphonates for bone protection Osteonecrosis of the jaw

Answer 117

Presentation - hot swollen joint with reduced range of motion Mx: needle aspiration before abx --\> fluids for 3Cs & G (cells, culture, crystals, gram stain) --\> empirical IV abx (based on aspiration) * S. aureus is most common * NOTE: if prosthetic joint - biofilm can be created - early (\<3m post-surgery)/delayed (\>3m) --\> more complicated, coag neg staph more common

Answer 118

Rules = **Ottawa rules** - for what ankle fractures qualify for an X-ray * Ankle XR: * Pain over malleolar zone * Tenderness along distal 6cm of the posterior edge of tibia/fibula * Inability to weight bear * Foot XR: * Pain over midfoot zone * Tenderness at base of 5th metatarsal/navicular bone * Inability to weight bear Classification = Weber classification - location of the fibula fracture in relation to the Syndesmosis (Distal Tibiofibula Syndesmosis - ligament between tibia & fibula) * Normal * A - fracture distal to the syndesmosis * B - fracture @level of the syndesmosis * C - Fracture above the syndesmosis * If also affecting the medial malleolus = bimalleolar fracture Ix: AP, lateral & oblique ankle X-ray * CT (distal tibia & hindfoot) - comminuted fracture * MRI - ankle ligaments & tendons Mx: depends on _Weber classification_ & level of _displacement_ * No to all Ottawa rules = conservative Mx: RICE – rest, immobilisation, compression, elevation * Unimalleolar: * No evidence of ligamentous injury on X-ray --\> _discharge w/ cast + fracture clinic follow-up X-rays_ * Evidence = UNSTABLE * Bimalleolar/unstable --\> _closed reduction (if joint dislocated on X-ray) --\> refer for surgical fixation_

Answer 119

Classic = 6Ps: pain, pallor, perishingly cold, pulseless, paraesthesia, paralysis (BUT these tend to be more associated with PVD than compartment syndrome) Typical presentation: tightness in compartment + acute disproportionate pain (worse on stretching) after _trauma_: * Acute is following fracture, soft tissue/reperfusion/thermal injury * Chronic (pain on exercise) often in long-distance runners * Other early sign = paraesthesia * Late signs: pallor, pulseless, paralysis RFs: Trauma, bleeding disorder (haemophilia), compartment support (tight cast/wrappings), burns, intense muscular activity (long distance runner) Ix: * Compartment differential pressure measurement - within 20-30mmHg = fasciotomy needed * +/- serum CK, urine myoglobin (rhabdomyolysis) Acute Mx: dressing release + morphine * 2nd line = complete fasciotomy (open all 4 compartments of lower leg) * 3rd line = amputation * If rhabdomyolysis —\> hydration +/- Na bicarbonate (urine alkalisation) +/- haemodialysis (metabolic acidosis) Chronic Mx: limit exercise + NSAIDs * 2nd line = fasciotomy

Answer 120

**NoF anatomy - blood supply:** * Deep femoral artery (the main branch of the femoral artery) - gives rise to: * Medial & lateral circumflex femoral arteries - gives rise to: * Retinacular arteries - progress superiorly up to the head of the femur * Artery of ligamentum teres - only a very small component of perfusion of the head/neck of the femur * NOTE: retrograde blood supply from distal to proximal **NOF anatomy - joint capsule** (ligaments surrounding the head of the femur and acetabulum): * Intracapsular - fracture within the joint capsule (proximal to the trochanteric line) - high risk of blood supply compromise as retinacular vessels sheared --\> Avascular Necrosis (AVN) * Extracapsular - fracture outside the joint capsule (distal to the trochanteric line) - less risk of blood supply compromise **RFs**: elderly, freq falls, osteoporosis, high impact trauma, post-menopausal women **Presentation:** externally rotated + shortened leg * Typically old, frail, osteoporosis/malacia **Ix:** * Examine joints above & below, NV exam of lower limb * FBC, U&E, LFTs, CRP, G&S (if NoF - need surgery) * Hip XR --\> CT/MRI (if normal X-ray but high suspicion) * NOTE: NoF fracture Xrays: **_Shenton line_** - if not smooth = likely fracture * **NoF fracture types - based on location:** * Sub-capital (slightly below the head) * Transcervical * Basicervical * Intertrochanteric * Subtrochanteric * **Garden classification - level of displacement:** * Stage 1 - incomplete (not all the way through the bone) * Stage 2 - complete (but fracture components intact) * Stage 3 - complete with _some displacement_ * Stage 4 - complete with _significant displacement_ Mx: * Conservative - analgesia * Medical - bisphosphonates (bone protection) + Vit D + DEXA * Surgical: * Subtrochanteric - internal fixation = _femoral nail_ * Intertrochanteric – internal fixation = _dynamic hip screw (DHS)_ * Intracapsular: * Undisplaced (Garden I&II) – cannulated hip screw or DHS * Displaced (Garden III & IV) - higher risk of AVN: * \<55yrs – reduction & fixation w/ screws * \>65yrs – replace: * Fit = _THR_ (HoF & acetabulum replaced) * Independent, mobile with ≤1 stick, no cognitive impairment * Not fit = _hemiarthroplasty_ (just HoF replaced)

Answer 121

**Types:** * Colles' fracture - common in A&E, fall on an outstretched hand --\> fracture of distal radius, displaced dorsaly (dorsum of the wrist) * Smith fracture - fall on flexed wrist, displaced in a palmar direction (palm of the wrist) * NOTE: displaced in the direction that is facing upwards (e.g. in Colles' the dorsal aspect is facing the sky; in Smith's the palmar aspect is facing the sky) **Mx:** * Check neurovascular intact * Imaging (visualise fracture) * _Reduction_ under haematoma block \> _Hold_ (e.g. cast) \> _Rehabilitate_ * NOTE: Smith's fracture is often more complicated --\> surgical intervention

Answer 122

* Joint erosion * Periarticular osteopenia * Ulnar deviation * Z-thumb * Swan neck

Answer 123

* Reduce (aligning fracture components) e.g. chole's fracture - haematoma block (provides anaesthesia as you manipulate different parts of the fracture) --\> traction/counter-traction * Hold e.g. with cast * Rehabilitate - regain function e.g. physio

Answer 124

**MSK X-RAY APPROACH:** * NOTE: likely knee or hip x-ray in the exam General: * Name, DoB ±PC * XR - date & time, views (AP/lateral), area of body, rotation, penetration (**_R_**I_P_E) * NOTE: always do _≥2 views_, compare to _previous X-rays_, look at imaging for _joints above and below_ **ABCS** approach: **A**lignment & joint space, **B**one texture, **C**ortices, **S**oft tissues * **Alignment & joint space:** * Changes suggest --\> fracture, subluxation (still touch) or dislocation * Displacement - describe the position of fragment distal to fracture site described * Joint space: * Narrowing due to cartilage loss/calcification (chondrocalcinosis)/new bone (osteophytes) * Subchondral sclerosis is increased bone density along joint lines (OA) * **Bone texture** - altered density (subchondral cyst - increased density, OA)/disruption (blurry - osteomyelitis) in trabeculae (inside of bone)/cortex (outer coating) * **Cortices** - trace around outside of each bone * Step = possible pathology: * Fracture * Bony destruction - inf or tumour (primary/secondary) * Periosteal reaction (new bone in response to injury/stimuli, appears as pale bone on the outside) - can be only sign of stress/healing fracture, mild osteomyelitis, tumour) * Soft tissues - swelling, foreign bodies (lipohaemarthrosis caused by fracture), effusions **DESCRIBE A FRACTURE:** Where - what bone? location (proximal, middle, distal OR epiphysis, metaphysis, diaphysis)? Does it involve articular surface (intra/extra-articular)? **Types:** _1. Simple vs Compound:_ * **Simple**: _closed_ fracture i.e. only bone involved * **Compound:** _open_ fracture i.e. bone exposed to the external environment - (↑risk of infection → ↑fracture non-union) Open fractures are emergencies and require urgent management with: * IV antibiotics * Tetanus prophylaxis * Wound debridement _2. Subtype:_ * Complete (all the way through the bone) * **Transverse:** perpendicular to long axis of bone * **Oblique:** tangential to long axis of bone * **Spiral:** oblique and rotating around the shaft * Comminuted: \> 2 fragments --\> CT to further assess * Impacted: broken ends of bone are jammed together by the force of injury, fracture line is indistinct * Linear: parallel to axis of the bone * Avulsion: bone attached to tendon/ligament is pulled away from main bone * Incomplete (not whole cortex, most common in children): * Greenstick: bone bends and cracks, occurs \< 10yrs * Salter-Harris: growth plate involvement Displacement - describe the position of distal fragment to body (anterior/posterior) * Angulation: change in bone axis (varus/valgus, dorsal/palmar, radial/ulna) * Translation: movement of fractured bones away from each other (% of bone width) OVERALL: 1) _Type_ (simple/compound \> subtype) 2) _Relevant region, side and name of bone_ 3) _Displacement_ (& angulation, translation) * Example: Simple oblique fracture of the proximal right tibia with posterior displacement

Answer 125

Presentation: 1st MTP joint, monoarticular (can be poly) Ix: Bloods (FBC, CRP, Urate), X-ray (errosive) Mx: * Acute: * NSAIDs * Colchicine * Oral Pred (5 days), steroid joint injection * Chronic: * Dietary advice - low purine, weight loss * Xanthine oxidase inhibitor e.g. allopurinol/febuxostat * Consider - uricosuric agents e.g. sulphinpyrazone, probenicid, benzbromarone * (NOTE: Rasburicase - tumour lysis syndromes)

Answer 126

Axial spondylitis Ix: * Spinal exam: _Schober's test_ - gross restriction \<3cm (should be 8-10cm) * X-ray: * Sacroiliitis * Sclerosis * Erosive damage * Widening joint space * (Fusion) * MRI scan whole spine & sacroiliac joints - detect pre-radiographic axial spondylitis * Sacroiliitis * Shiny corners (Romanus lesions) Mx: * Analgesics + NSAIDs * TNF-alpha blocker (or IL-17 blocker)

Answer 127

Def: multisystem disease - inflammation, vascular abn, fibrosis Presentation: digital ulcers, tight skin around hands/mouth Subsets: * Limited cutaneous SS (CREST) - skin changes limited to forearm/calf/distal/peri-oral area * Diffuse cutaneous SS - more extensive, upper arms, legs, trunk Presentation: * Swelling of hands & feet, Reynaud's phenomenon, skin thickening * Heartburn/reflux/dysphagia, bloating * Arthralgia/myalgia * Dyspnoea & dry crackles (pul fibrosis, pul HTN) * Scleroderma renal crisis (renal failure, marked HTN) Ix: * Bedside: ECG, urine dip, pulmonary function tests (pul fibrosis) * Bloods: * FBC, U&E, LFTs, CRP/ESR, * Abs: ANA (also in SLE, AI hep), **anti-centromere** (limited cutaneous), **SCL-70 aka topoisomerase** (diffuse cutaneous) * Imaging: CXR, Echo, barium swallow Mx: * Specialist MDT * Conservative: smoking cessation, **emollients**, avoid cold/gloves (Raynaud's), physio, OT * Medical: * CCB (nifedipine) for Raynaud's * Omeprazole, prokinetic (domperidone) for GI Sx * Analgesia (for joint pain) * ACEi (for HTN) * **Steroids + IS** (methotrexate) --\> if diffuse disease/complications (pul fibrosis) * Scleroderma renal crisis - ACEi + renal dialysis/transplant

Answer 128

Causes muscle inflammation + skin rash Presentation: Gottron's papules, heliotropic rash, proximal muscle weakness Ix: CK, ANA/myositis ab panel, MRI of involved muscle, electromyogram, muscle biopsy

Answer 129

GCA is most common primary vasculitis **Presentation:** headache, scalp pain/tenderness, aching & stiffness, jaw/limb claudication * Loss of vision - can have amaurosis fugax, blindness if vision not treated within hrs * Commonly associated with polymyalgia rheumatica (PMR) **Ix:** * ESR & CRP * USS temporal artery --\> bilateral temporal artery biopsies - up to 2wks after high-dose steroids **Mx:** prednisolone, if visual Sx consider IV methylprednisolone * If persistent active/relapsing - IL-6 receptor blocker (Tocilizumab)

Answer 130

Def: inflammatory rheumatological condition Presentation: muscle aches and joint stiffness * Profile: elderly woman (\>70yrs) * Difficult to rise from seated/prone position * Shoulder/hip stiffness & bursitis * muscle tenderness & oligoarthritis Associated with **GCA** (15-20% have GCA; 40-60% GCA have PMR) * GCA is most common primary vasculitis * Can have amaurosis fugax, blindness if vision not treated within hrs * Ix: _bilateral temporal artery biopsies_ - up to 2wks after high-dose _steroids_ Dx: clinical + **ESR, CRP**, FBC (to rule out haem disorders) Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates) * Other: methotrexate + folic acid

Answer 131

Tenosynovitis def: * Involves extrinsic tendons of hand & wrist & corresponding retinacular sheath * Characterised as tendon irritation manifesting as pain --\> progress to catching and locking when tendon gliding fails. RFs: insulin-dep DM, pregnancy/lactation, dom-hand involvement Presentation: location over retinacular sheat, pain increases with motion, * **Trigger finger:** * _Painful popping_ on finger flexion/extension (catching of flexor tendon) * Palpable nodule @level of metacarpal head in palm * **De Quervain's disease:** * Pain, tenderness, swelling localised to _radial wrist_ (1-2cm proximal to radial styloid) * Worse on thumb mov/ulnar deviation * Finkelstein test (thumb in hand + ulnar deviation --\> pain) * **Intersection syndrome:** * Pain & swelling _4cm proximal to wrist joint_ ± redness/palpable crepitus * Much worse on resisted wrist extension * Extensor pollicis longus: * Thumb IP mov --\> pain @Lister's tubercle * Extensor carpi ulnaris: * Ulnar wrist pain * Worse with extension/ulnar deviation against resistance * Flexor carpi radialis: * Pain @palmar wrist crease over scaphoid tubercle + along tendon ± localised swelling/ganglion cyst * Worse with resisted wrist flexion, radial deviation Ix: **high-res USS** Mx: * NSAID ±splinting * CS injection (sheath/compartment): flexor tendon sheath (trigger finger), 1st dorsal compartment (De Quervain's disease) * Surgery (surgical release of compartment)

Answer 132

**Def:** abrupt loss of kidney function resulting in dysregulation of _fluid balance_ + _electrolytes_ & _retention of nitrogenous waste products_ **Severity** defined based on creatinine/urine output: * **Stage 1:** 1.5-1.9x baseline/UO \<**0.5**mL/kg/hr for **6-12hrs** * **Stage 2:** 2-2.9x baseline/UO \<**0.5**mL/kg/hr for **\>12hrs** * **Stage 3:** \>3x baseline/UO \<**0.3**mL/kg/hr for **\>24hrs** _OR_ **anuria \>12hrs** Breakdown by pathology: * **Pre-renal** - HYPOPERFUSION * Hypovolemia (e.g. dehydration/upper GI bleed -\> less circulating volume) * Sepsis/Anaphylaxis (widespread vasodilation -\> reduced perfusion pressure) * HF (heart pumping less effectively -\> less blood reaches kidneys) * RAS (mechanical obstruction of blood flow to kidneys) * **Renal** - KIDNEY-SPECIFIC --\> renal referral * Acute tubular necrosis (following pre-renal AKI, high CK) * Glomerulus = Glomerulonephritis * Interstitium = acute interstitial nephritis (low-grade fever, _elevated urinary eosinophils_, commonly from NSAIDs) * Blood vessels = vasculitis * Toxin accumulation = nephrotoxic drugs (ACEi, thiazide diuretic), rhabdomyolysis (myoglobin) * **Post-renal** - OBSTRUCTION --\> urology referral * Ureteric calculus * BPH * Cancer (prostrate, bladder) Ix: * Bedside - urinalysis (haematuria, inf, BM, PCR) * Red cell casts - glomerulonephritis * White cell casts = pyelonephritis * Bloods - U&E, AI screen (ANCA), CK * Imaging - renal USS (stones, vascular thrombosis) Mx: * Identify & Mx the cause * Hypovolaemic - IV fluid bolus * Hypervolaemic - if pul oedema --\> loop diuretic (furosemide) + Na restriciton

Answer 133

**Def:** slowly progressive hyperplasia of periurethral (transition) zone of prostate gland --\> urinary outflow obstruction * Common - occuring primarily in elderly men **Sx:** lower urinary tract symptoms (FUND HIPS) **Ix:** urinalysis (UTI), PSA (cancer) ± US/CT (abdo/pelvis)/cystoscopy **Mx:** * Acute retention = _CATHETERISE_ * Conservative - watchful waiting * Medical: * _Alpha-blocker_ (relax sm muscle around prostatic urethra) e.g. **tamsulosin** * _5-alpha-reductase inhibitor_ (reduce conversion of testosterone --\> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. **finasteride** * Surgical: **TURP** (transurethral resection of the prostate - shave extra prostate), open prostatectomy * NOTE: TURP not curative - will continue to grow

Answer 134

**Def:** crystal deposition within the urinary tract **Presentation:** severe loin to groin pain (ureteric colic - starts around back and moves towards groin) **Stone types:** * **Ca oxalate (80%)** * Mg Ammonium Phosphate (struvite) - likely **_staghorn calculi_** * Associated with **_proteus mirabilis_** inf * Urate * Cysteine **Ix:** * Bedside - urine dip (microscopic haematuria) * Bloods - U&E (post-renal AKI) * Imaging - gold standard **_non-contrast CT KUB_** (kidneys, ureters, bladder) * Contrast is excreted by kidneys - looking for bright white light of Ca --\> if you give contrast it will mask the finding Mx: * Infected & obstructed = **pyonephrosis** --\> URGENT decompression via **_NEPHROSTOMY_** (or retrograde w/ JJ stent) * Opening between kidney & skin w/ nephrostomy bag for external collection * Nephro (kidney) stomy (opening) * \<5mm (on CT) - allow spontaneous passing, retain stone for analysis * \>5mm (on CT): * **Ureteroscopic lithotripsy** - endoscope into ureter & using mechanical force/laser to destroy stone * Uretero (through ureter) scopic (camera) Litho (stone) tripsy (crush) * **Extracorporeal shockwave lithotripsy** - external USS to destroy stone * Extra (outside) corporeal (body) shockwave (USS) Lithtripsy (crushing stone) * **Percutaneous nephrolithotomy** - ONLY if stone in kidney (e.g. staghorn calculi), extract stone through skin in back * Percutaneous (through skin) Nephro (kidney) lith (stone) otomy (cutting) When to ADMIT: * Pain not controlled * Significantly impaired renal function * Single kidney * Pyrexia/sepsis * Stone \>5mm If managed at home: * High fluid intake + return if pain worsening/develop temperature * OPA in 4 weeks with CT-KUB on arrival --\> if stone still present need lithotripsy/nephrolithotomy

Answer 135

**DDx:** * _Testicular torsion_ - EMERGENCY & TIME-URGENT * Elevated testis, loss of cremasteric reflex, very tender * Tx: bilateral orchidopexy (orchidectomy - if necrotic) * **Can you feel above swelling?** * YES - **swelling separate from testis?** * YES - _Epididymal cyst_ OR _Varicocele_ * NO - **Tender?** * YES - _Epididymo-orchitis_ * NO - _Hydrocele_ OR _Tumour_ * NO - _Inguinal hernia_

Answer 136

**Kidney glomerular structure:** * Capillary \> Endothelial cells \> Glomerular basement membrane (GBM) \> Foot processes of podocyte * Podocyte function: prevent protein leaking into the filtrate **Nephritic = proliferative** - inflammation of glomerulus & nephrons --\> capillary becomes leaky --\> **_blood & protein leak_** * Key: blood, protein, increased creatinine, possible trigger (e.g. inf), acute/subacute disease progression * Causes: often immune-mediated * **Post-streptococcal glomerulonephritis** - molecular mimicry - antigen in kidneys accidentally recognised as strep antigen after inf * Nephritic - more HTN * _**Weeks** after GAS inf (pharyngitis, skin)_ * **Ix:** ASO titre (high/low C3) * **Mx:** conservative - BP control * No long-term problems * **IgA nephropathy** (Berger's disease) - generate abn IgA --\> abs attach & form immune complexes = sticks & get stuck in glomerular capillaries --\> activate compliment --\> inflammation * Nephritic - more proteinuria * Sx: abdo pain, rash, arthritis * _**Days** post-resp/GI inf_ * **Mx:** BP control, steroid * 40% get renal failure * Assoc w/ IgA conditions (HSP, Coeliac disease) * **Henoch-Schonlein Purpura (HSP)** - related to IgA nephropathy but is _WIDESPREAD_ (IgA limited to kidneys) * **Purpuric rash (buttocks/extensors)**_,_ arthritis, abdo pain, Hx URTI * **Mx:** spontaneous resolution ± steroids * Haemolytic Uraemic Syndrome (HUS) - MAHA, thrombocytopenia, E.Coli (O157) * Goodpasture's syndrome (anti-GBM disease) - pul haemorrhage, rapidly progressing glomerulonephritis + _anti-GBM abs_ * Granulomatosis with polyangiitis (Wegner's) - chronic sinusitis + lung haemorrhage, _PR3_ (cANCA) * SLE **Nephrotic = non-proliferative** - (urinary protein loss \>3.5g/day) from _Podocyte effacement_ * NOTE: 24-hr urine collection not commonly done so better marker is spot urine **protein: creatinine ratio** _\>300mg/mmol_ * Key: **_high protein_**, hypoalbuminaemia, oedema (face), thrombosis (main coag factor loss in urine is anti-thrombin 3 = one of the bodies main anticoagulant mechanisms --\> hypercoagulable state) --\> VTE * _Renal biopsy_ to determine type --\> causes: * Minimal change disease - children --\> Tx: steroids * Focal segmental glomerulosclerosis - most common in adults, assoc w/ obesity, DM & HIV * Membranous glomerulonephritis - 2nd most common in adults, idiopathic * Amyloidosis --\> Ix: CONGO RED STAIN

Answer 137

Epidemiology & mets: * Mets to para-aortic LNs * Most common malignancy in males 20-40yrs Ix: * Blood testicular tumour markers: alpha-fetoprotein, beta-hCG, LDH (necrosis, others secreted by tumour itself) * Testicular US --\> CT-CAP for staging (would likely do orchidectomy before CT) * Urine dip (look for infection) --\> culture Mx: * **Orchidectomy** – take _inguinal_ approach (scrotal approach risks mets and inguinal is coming out the same way the testicle drops) - only time would not do this first is when respiratory compromise then would do chemo first * **BEP chemotherapy** follow-up = very good response typically * Very good prognosis - good/intermediate prognosis groups have \>90% 5-yr survival

Answer 138

* Acute - pain * Chronic – no pain * Low pressure * High pressure – renal impairment + hydronephrosis * LUTS with nocturnal enuresis Acute Ix: * DRE - men & women (also PV exam) * Urine dip + MC&S * Bloods - FBC, U&E, PSA * Imaging - bladder scan (for acute), US KUB (for chronic) * Meds review: * stop anticholinergics * analgesia if needed * laxatives for constipation

Answer 139

**Def:** collection of fluid in tunica vaginalis **Ix:** US, testicular tumour markers (AFP & bHCG - secreted by tumour, LDH - necrosis), urine culture (inf) **Causes:** idiopathic, inf, trauma, tumour

Answer 140

Def: distended veins of pampiniform plexus Key points: * More common on left (the way left testicular vein drains into left renal vein) * Assoc w/ infertility, renal cancer * Swelling may reduce when lying down

Answer 141

Most common = transitional cell carcinoma (urothelial) Presentation: * Painless visible haematuria (or asymptomatic non-visible haematuria) * Irrigative LUTS (urgency, suprapubic pain) * Recurrent UTIs * Pain, weight loss, lymphoedema Ix: * Initial: * Urine dip (blood, leucocytes) * MC&S (use MSU - RBCs & WBCs, no bacterial growth) * Bloods - FBC * **Flexible cystoscopy** (lower urinary tract) + **CT-urogram** (upper urinary track if visible haematuria --\> if non-visible low-risk use _US_) * Dx & staging = **_Transurethral Bladder Tumour Resection (TURBT)_** - resects full tumour + histology * Intravesical therapy: * Bacillus Calmette-Guerin (BCG) instilled into bladder --\> reduces superficial bladder cancer recurrence (causes immune response to remaining tumour cells, same substance as in BCG vaccine) * Mitomycin - cytotoxic chemo agent Mx: 2wk wait urology * Muscle invasive = cystectomy (young people) or radiotherapy/chemotherapy (older) * Superficial = surveillance cystoscopies, intravesical chemo * Mets = systemic therapy

Answer 142

Presentation: ALL can cause **renal impairment** + rash (e.g. shins) ± low-grade pyrexia/fatigue Ix - Rheumatological Ab screening: * ANA * ANCA * + biopsies of BVs/affected organs e.g. kidneys _cANCA = PR3:_ * **Granulomatosis with polyangiitis (GPA)** aka Wegener's * Nasal bridge collapse/epistaxis, _chronic sinusitis_ * DDx for nasal bridge collapse can be cocaine abuse * Can develop _pulmonary nodules/haemorrhage_ * Granulomas * Case: 52yrs, cough with blood, malaise, rashes, SoB, sinusitis for yrs * ABG - reduced PaO2, raised creatinine, cANCA +ve _pANCA = MPO_ (myeloperoxidase): * **Eosinophilic granulomatosis with polyangiitis (EGPA)** aka Churg-Strauss * Asthma + _eosinophilia_ + _mononeuritis multiplex_ (e.g. weakness in hand) * Granulomas * Microscopic polyangiitis - no granulomas Tx: * Remission: cyclophosphamide + CSs * Maintenance: low-dose CSs + methotrexate

Answer 143

Presentation: sudden-onset pain, high fixed position, absent cremasteric reflex Tx: bilateral orchidopexy (both sides as increased risk of torsion in the other side)

Answer 144

Ix: * PR exam, PSA * FBC, U&E, LFTs * Transrectal ultrasound (TRUS)-guided needle biopsy * Gleason score = PC grading * TNM staging * Multiparametric MRI Mx: surgery/radiotherapy * Radial prostatectomy ± LN dissection * External beam radiotherapy/brachytherapy * Androgen-deprivation therapy (ADT)

Answer 145

Def: renal tubular dysfunction/detachment from the basement membrane * Most common intrinsic renal cause of AKI * Causes: * Chronic ischaemia of renal tubules (shock/LVF) - initially pre-renal AKI * Nephrotoxic (lots of myo/haemoglobin, contrast, aminoglycosides e.g. gent, Ig light chains) * Can't concentrate urine or regulate electrolytes --\> high UO, _high urine sodium_

Answer 146

Cellulitis/Erysipelas Venous thrombosis (DVT) Chronic venous insufficiency

Answer 147

Meningococcal septicaemia DIC Vasculitis Acitinic purpura

Answer 148

Melanocytic naevi Seborrhoeic wart Malignant melanoma

Answer 149

Eczema - atopy/exacerbating factors Scabies - contacts with Hx Urticaria - precipitant Lichen planus - FHx/drug-induced general Mx: antihistamines, CS

Answer 150

Ix: FBC, haematinics, B12/folate, OGD **Blood transfusion threshold:** Hb \<70 or \<80 _AND_ ACS Other options: Fe infusion, ferrous fumarate NOTE: anaemia can exacerbate chest pain/ACS

Answer 151

**Def:** Acute confusional state caused by a physical condition **Causes:** U PINCHES ME * **Urinary retention** * **Pain** * **Infections** * Nutrition * **Constipation** * **Hydration** * Endo & electrolytes * Stroke * **Medications** & alcohol * Environmental **Delirium screen:** - FBC, U&E, LFT, glucose, BC, _Ca, TFTs, B12/folate_ - Urine dip + MC&S - CXR, possibly CT-head **Management:** Tx cause * Conservative: lighting, clocks, 1:1 nursing, adequate hydration, laxatives, involve family/carers * SOS (risk to themselves/others): * Lorazepam (PO/IM/IV) * Haloperidol (PO/IM) - be careful if Parkinson's --\> worsens Sx

Answer 152

ABCDE * Stop suspected cause * Secure airway, give 100% oxygen, +/- intubate if respiratory obstruction imminent * **IM 0.5mg adrenaline (1:1000)** * **IV 10mg chlorpheniramine** * **IV 100mg hydrocortisone** * Treat bronchospasm – salbutamol +/- ipratropium Going forward: * Maintain fluids + monitor pulse oximetry, ECG and BP * If still hypotensive, may need transfer to ICU and an IVI of adrenaline +/- aminophylline (bronchodilator) and nebulised salbutamol After acute episode: * Admit to ward and monitor ECG, _monitor for 6hrs for biphasic reaction_ * Measure **_mast cell tryptase_** 1-6 hours after = confirm anaphylaxis * Continue chlorpheniramine * Suggest MedicAlert bracelet with name of culprit allergen * Teach about self-injected adrenaline & give auto-injector * Skin prick tests showing specific IgE to help identify allergens to avoid

Answer 153

3 in, 3 out All within 1hr

Answer 154

IV adrenaline

Answer 155

DC shock (150J biphasic) Adrenaline 1mg IV (10ml 1:10,000) Amiodarone 300mg IV (if shockable rhythm)

Answer 156

Airway and _cervical spine_ Next - CT-head + CXR

Answer 157

* **Def:** a sudden decrease in limb perfusion that threatens the viability of limb * AF = major RF for acute limb ischemia * **Presentation** - 6Ps: * Pale * Pulseless * Painful * Perishingly cold * NOTE: need immediate vascularisation (\<6hrs) if: * Paralysis * Paraesthesia (esp worrying) * **Ix (after initial Mx):** * Bedside: ABPI (PAD), ECG (AF) * Bloods: FBC, U&E, clotting, HbA1c, lipid profile * Imaging: duplex USS, CT/MR angiography * **Mx:** * Initial: * A-E, IV access, analgesia * **IV heparin infusion** - reduces the chance of the clot getting worse * Limb viability: * Immediate - tender muscles, loss of power, loss of sensation * Urgent - pale, pulseless, painful, cold * Irreversible - fixed, mottled skin, woody, hard muscles * Refer to vascular surgery: * Thrombotic - _local intra-arterial thrombolysis_, angioplasty, bypass * Embolic - _embolectomy_/local intra-arterial thrombolysis/bypass

Answer 158

* Both sides all reduced pulse = aorta-iliac --\> aorto-bifemoral * One side reduced pulse from the popliteal down = femoro-popliteal * One side reduced pulse distally in anterior tibial = femoro-distal * One side reduced pulse distally in posterior tibial = femoro-distal

Answer 159

**Def:** limb ischemia (chronic) from atherosclerosis in lower limb vasculature **RFs:** male, older, smoker, HTN, DM **Spectrum:** * **Intermittent claudication** (mild) - cramping leg pain after walking (& have to stop) + _relieved by rest_ * NOTE: the equivalent of stable angina (worse on exertion) * Worse going uphill/upstairs * **Critical limb ischemia** (severe) - ulcers, gangrene, night pain & _rest pain_ * NOTE: the equivalent of unstable angina (present at rest) **Ix:** * Bedside: * Exam special test = _Buerger's angle_ - elevation pallor --\> sudden drop feet down = sunset sign * exercise-treadmill ABPI (ankle-brachial pressure index) - \<0.8 (\<0.3 = CLI) * Bloods - FBC, U&E, LFTs, CRP, clotting * Imaging: * Arterial duplex USS * CT/MR angiography **Mx:** dealt with by vascular surgeons --\> optimise meds + surgery (bypass) * Conservative: smoking cessation * Medical: ACEi, clopidogrel, statin, DM control * Surgery: angioplasty/stent/bypass graft/amputation

Answer 160

Sx: * Central abdo pain * Radiates to back * Bloating * Pulsatile mass on palpation (expansile - moves to sides) * NOTE: always consider if abdo pain + RFs (male, \>65yrs, HTN, smoking etc.) Ruptured AAA Sx: * Severe pain radiating to back * Visible pulsating abdo mass * Shock (circulatory compromise) Ix: * Abdo duplex USS if part of national screening - male age 65yrs * CT angiography if stable but suspicious of rupture Mx: * **\<5.5cm** --\> Conservative: monitor w/ USS + RF modification * \<4.5cm --\> yearly USS * 4.5≤x\<5.5com --\> 3 monthly USS * Medical: optimise BP control, statin, aspirin * **Sx/\>5.5cm/expanding \>1cm/yr** --\> Surgical: endovascular (catheter into aorta to insert stent)/open repair

Answer 161

NOTE: **if press harder and it is there = my own pulse; if press weaker and it is there = their pulse** * If can't feel pulses can use **_doppler USS:_** triphasic signal * 1st phase - forward rush of blood * 2nd phase - reverse flow from elastic recoil (in arterial wall) * Lost in arterial disease = biphasic/monophasic signal * 3rd phase - forward flow on vessel relaxing **EXAMINATION:** General inspection – smoking, inhalers, diabetic meds, fistula, dressings, walking stick Upper: * Hands – splinter haemorrhages, nicotine stains, missing digits (more common in trauma, Buerger’s disease), temperature + **CRT** * Supra-aortic pulses: * Radial – rate, rhythm, **radio-radial delay** * Brachial pulse – character * Subclavian pulse, in supraclavicular fossa * Carotid pulse * BP * Listen for bruits in neck, breathe in and out slowly Abdo: * Inspect for scars, look around sides * Palpate for aneurysms - abdominal aortic pulse * Listen for aortic and renal bruits (above umbilicus and to either side) Lower: * Inspect (colour, swelling, scars, varicose veins) * Palpate: * Temp in feet, calves, thighs (run back of hand along) * Tenderness - squeeze ankles/calves (DVT) * **CRT**, pitting oedema * Measure leg diameter 10cm below tibial tuberosity (If \<3cm between = not significant) * Femoral arteries (ASIS & pubic symphysis midpoint): * Feel simultaneously as weak femoral pulse difficult to determine * Radio-femoral delay * Auscultate femoral pulse for bruits (can also listen to iliacs - below umbilicus on either side) --\> sometimes only picked up on exercise * Popliteal arteries – reach around back of knee, behind the knee, slightly lateral, lift leg up to 30 degrees so weight resting on fingers * Pedal arteries – anterior (dorsalis pedis) & posterior tibial (behind medial malleolus) * BUERGER’S TEST (for peripheral vascular disease) * Both feet held up – angle foot goes white is Buerger’s angle --\> when foot blanches swing legs over side of bed and let them hand down --\> ischaemic foot will go brick red = severe peripheral vascular disease of lower limb = SUNSET SIGN * Ideally, I should hold feet for 1 minute but still say -ve test if no blanching * ABPI: * BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler USS * Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure * Repeat procedure in arm using brachial artery signal to record the brachial pressure * ABPI = ankle pressure/brachial pressure * 0.5-0.8 = claudication (mild-moderate disease); \<0.5 = rest pain (severe disease); \<0.2 = gangrene Finally - complete relevant neuro exam, vascular exam where not been done in exam, CV & abdo exams * Bloods - FBC, U&E, coag * D-dimer, duplex USS (venous - DVT/arterial - perfussion) --\> CTPA (PE) * Tx: DOAC/Warfarin if high-risk DVT **Leg Anatomy:** * **Arterial:** * External iliac artery \> _femoral artery_ (pulse): * Profunda artery (minor branch) * Superficial femora artery (main branch) \> _Popliteal artery_ (pulse): * Anterior tibial artery - form _dorsalis pedis artery_ (pulse) * _Posterior tibial artery_ - goes around medial malleolus (pulse) * Peroneal artery (branch of PTA) * **Venous:** * _Great-saphenous vein_ (medial) - meets deep femoral vein in medial upper thigh (as goes into groin) * _Small-saphenous vein_ (lateral) * Connected via perforating vein

Answer 162

Presentation: * Oedema, haemosiderin deposition, lipodermatosclerosis (inverted-champagne bottle), eczema, venous ulcers * Varicose veins - dilated tortuous, superficial veins * Pain, swelling, itching, restless legs, cramps * Feel for thrombosis (hard = thrombophlebitis) * Cough impulse at SFJ (for _Saphena Varix_ - dilation of saphenous vein @junction w/ femoral vein) * _Trendelenburg test_ * Lying flat, lift up leg & empty veins * Compression over SFJ --\> stand up (maintain pressure) - if do not fill = competent valves below SFJ * If do fill = incompetent valves below SFJ (blood flow from deep to superficial vein via perforating veins) * Repeat with pressure lower down until filling stops * Perthe's test - apply tourniquet to mid-thigh + walk for 5-mins --\> compresses superficial vein * Less distended - normal deep veins as calf compression pushes blood into deep venous system * Remain distended - impaired deep veins * Doppler US for reflux * Warfarin - previous DVT * Abdo mass with compression Ix: duplex USS (allow DVT to be ruled out) Venous insufficiency Mx: * ABPI \> 0.8 --\> Compression bandaging * Varicose veins: * Conservative - weight loss, avoid standing for prolonged periods * Minimally invasive procedures - injection sclerotherapy, endovenous radiofrequency ablation * Surgical - vein ligation Varicose Veins complications: * thrombophlebitis - Tx for superficial: NSAIDs * Eczema * Bleeding * Haemosiderin deposition * Lipodermatosclerosis (champagne bottle) * Ulceration

Answer 163

Causes: * Failures: * Liver cirrhosis due to alcoholism (failure of liver to metabolise oestrogens) * Renal failure * Neoplasm: * Bronchial carcinoma * Pituitary tumours (hyperprolactinaemia) * Testicular tumours * Hyperthyroidism, Hypogonadism * Drug-related (spironolatone) Presentation: elderly/puberty Dx: bilateral USS Mx: * Cause * Tamoxifen * Surgery * NOTE: do not stop meds just because they are causing gynecomastia

Answer 164

Def: tear in **tunica intima** (inner layer of BV) --\> blood collection between tunica intima and tunica media --\> _false lumen_ (can occlude blood flows through aorta) --\> AR, myocardial ischaemia, stroke Sx: sudden onset, central tearing chest pain --\> radiating to between shoulder blades * Hx of intermittent claudication * Haemodynamic instability (high HR, low BP) * Before left subclavian artery - left arm smaller than right arm * After left subclavian artery - lower body less developed than upper body Ix: * BP in both arms - radio-radial delay * ECG, CXR (widened mediastinum) * Gold-standard: _CT-aortogram w/ contrast_ Mx: * Stanford A (ascending aorta) - more WORRYING (compromise blood to brain, cause aortic regurg): * BP control - _B-blockers & CCB_ (aim 100-120mmHg) * **Immediate referral for vascular surgery** * Stanford B (descending aorta) * BP control - _B-blockers & CCB_ (aim 100-120mmHg) * Urgent referral to vascular surgery (repair likely if complicated)

Answer 165

Breast anatomy - Lobules \> ducts \> nipple * Ligaments suspending breast = _Cooper's ligaments_ * Most lymphatic drainage to _axilla_ (& intercostal, interthoracic LNs) * Blood supply - _perforating intercostal arteries_ Intro - WIPE + chaperone Inspection: * **SITTING** Positions: * Relaxed arms * Hands rested on thighs * Hands-on hips - tense pectoralis * Hands behind head - accentuate dimpling/asymmetry * Lift breasts - submammary fold (ask patient) * Look for: * Asymmetry, local swelling, scars (look under breasts) * Skin changes: * Dimpling/puckering - tethering due to cancer * Peau d'orange - lymphatic oedema due to cancer * Nipple changes: * Paget's disease of breast - unilateral nipple = cancer * Eczema - areola (rarely nipple), bilateral * Inversion - normal variant/cancer Palpation: **LYING DOWN** + hand on the side being examined _behind head_ + check for pain (start on normal side) * Use palmar surface of middle 3 fingers to feel for any lumps starting in centre and going round in concentric circles * Pinch along axillary tail (first 2 fingers & thumb) * Ask patient to squeeze each nipple to check for discharge * Localise + describe lump: **3Ss, 3Cs, 3Ts** * Site, Size, Shape * Consistency, Contours, Colour * Tenderness, Temperature, Tethering/Transillumination * Lymph nodes: * Axillary - ask patient to hold bicep: * Palpate apical, lateral, medial, anterior, posterior aspects * Cervical LN exam * Offer to examine lungs and liver for mets Triple assessment: * Examination * Imaging (USS \<35yrs; MMG + USS ≥35yrs) * Biopsy (FNA if cystic, core biopsy if solid)

Answer 166

Venous: * Hx: **varicose veins, previous DVT**, obesity, preg, recurrent phlebitis * Location: lower calf-medial malleolus * Characteristics: mild pain * Ulcer - **shallow/flat margins, exudate,** sloughing @base, granulation tissue * Surrounding skin - **haemosiderin staining, eczematous, oedematous**, thickening skin, (normal CRT) * Tx: **compression bandaging**, leg elevation, surgical Mx Arterial: * Hx: **HTN**, DM, smoking, prev vascular disease * Location: **pressure points**, toes/feet, lateral malleolus, tibia * Characteristics: painful * Ulcer - **punched-out/deep**, irreg shape, necrosis, no exudate (unless inf) * Surrounding skin: thin, shiny, reduced hair, **6Ps** (pallor, pain, perishingly cold, pulselessness, _paraesthesia, paralysis_) * Tx: revascularization (e.g. bypass), anti-platelet, manage RFs Neuropathic: * Hx: **DM** (peripheral neuropathy), trauma, prolonged pressure * Location: plantar foot, tip of toe, lateral-fifth metatarsal * Characteristics: no pain * Ulcer - **deep, surrounded by callus, insensate** (no feeling) * Surrounding skin - dry, cracked, callus, insensate * Tx: off-loading pressure, topical GF Pressure: * Hx: limited mobility * Location: bony prominence, heel * Characteristics: * Ulcer - deep, macerated (moist, wrinkly) * Surrounding skin - atrophic skin, lost muscle mass * Tx: off-loading pressure, reduced moisture, increased nutrition

Answer 167

Screening MMG * ≥50yrs - 3yrly * \>40yrs - attending clinics USS focused: * \<35yrs USS only * ≥35yrs USS + MMG Biopsy: * all breast lumps in women \>25yrs * USS-guided

Answer 168

**Breast pain** * Presentation: * Benign breast pain, cyclic/non-cyclic (**fibrocystic breast)** * Other causes - inf, trauma (fat necrosis), haematoma (on anti-coag) * Dx: nothing if no masses/concerning features on exam * Mx: * Reassurance, supportive bra * Ibuprofen/voltarol gel * Evening primrose oil **Breast Cyst** * Presentation: * Sudden tender, small, smooth lump --\> disappears after a period * Multiple w/ previous similar episodes * Younger * Dx: * USS only \<35ys; USS + MMG ≥35yrs * USS - fluid-filled, well-circumscribed collection * Disappears after aspiration, biopsy if solid posterior residual lesion * Mx: USS-guided aspiration only if large + painful **Fibroadenoma** - common benign breast tumours of both glandular and stromal tissue * Presentation: * Mobile, easily palpable, can be lobulated * Young women * Dx: * Age-dependent * Biopsy \>25yrs/very large/concerns over phyllodes tumour * Re-scan small FAD again in 3-6 months to monitor for rapid enlargement * Mx: * Surgical excision - if rapid enlargement/\>4cm * Reassurance otherwise **Mammary duct ectasia** (periductal mastitis) * Presentation: * Milk ducts dilate and fill with fluid --\> breast pain + green-white nipple discharge * Assoc w/ smoking, menopause * Dx: can mimic breast cancer --\> need triple assessment * Mx: conservative ± abx ± surgery for complications **Breast abscess** * Presentation: * breast-feeding, DM, post-op, smokers * Red, hot, tender fluctuant mass, systemic (febrile, unwell) * Acute Hx * Dx: * Too painful to tolerate MMG - USS only initially * MMG on resolution if ≥35yrs * Mx: * USS-guided aspiration + Abx * Clinical review in 48hrs --\> possible repeat aspiration * Incision & drainage under GA if overlying necrotic skin

Answer 169

Causes: * Physiological (90%) * Duct ectasia - benign, normal in post-menopausal, multi-duct * Intraductal papilloma - papilloma growth in single duct * Epithelial hyperplasia * Galactorrhoea - pregnancy/prolactinoma Presentation: * Smokers - green multi-duct * Duct ectasia (dilated ducts) - yellow multi duct --\> _cheesy watery discharge_ ± bloodstained * Prolactinoma/pregnancy - b/l milky, multi duct * Underlying pathology (cancer, PCIS, papilloma) - bloody discharge from a single duct (can be watery/serous) * Epithelial hyperplasia has a similar but less severe presentation Dx: * Age-related ± MRI * USS retro-areolar w/ biopsy of visible lesions Mx: * Treat cancer incl. excision of NAC * Papilloma - single/total duct excision

Answer 170

RFs: * Increase: * FHx (breast, ovarian, colon) * Genetic mutations (BRCA1/2 - sign increase risk of breast/ovarian cancer) * Post-menopausal, ≥40yrs, early menopause/late menarche * OCP (decreases risk of endometrial/ovarian/colorectal) * Decrease: pregnancy, breastfeeding Types: * **Invasive ductal carcinoma** - 70%, firm/hard * Lobular carcinoma - 10%, bilateral in 20%, multicentric * Tubular - 10%, small stellate lesions, picked up on screening * Other: medullary (soft/fleshy, good prog), mucoid (rare, good prog), Paget's (nipple excoriation, underly intraductal tumour, poor prog) Receptor involvement: ER (oestrogen), PR (progesterone), HER2 (Herceptin) * ER/PR-receptive = good prognostic signs * HER2 = bad prognostic sign (but now Tx for it) Presentation: * Post-menopausal * Firm mass ± skin tethering/dimpling * LNs in axilla Ix: * Triple assessment: * ≥35yrs - MMG + USS + biopsy (FNA/core biopsy) * \<35yrs - _USS + biopsy_ --if proven cancer--\> MMG + MRI * Axilla - USS + biopsy if any abnormal LNs * **Staging** CT & bone scan if \>3cm/LNs involved - TNM * T1-4 (size, 4= invasive), N0/1 (no/yes), MO/1 (no/yes) * Mets - _bone_, lung, liver * **_Nottingham prognostic index_** - size & grade of tumour & LNs * MRI if lobular cancer Mx: * ALWAYS - _Surgery:_ * __Mastectomy/wide local excision - depends on tumour size vs breast size * ALWAYS - _SLNB/ALNC_ * Sentinel LN biopsy vs axillary LN clearance = remove all * Chemo - if involve **LNs**/large cancer/young patient/**HER2 +ve/Triple -ve disease** * Radio - \>4cm, LN involvement, skin/muscle involvement * Endo: ONLY if ER +ve * _Tamoxifen_ pre-menopausal * Letrozole if post-menopausal * Herceptin (Trastuzumab) for HER2+ * MDT approach (incl psychological support)

Answer 171

BP targets: * \<140/90 * \<150/95 for over 80yrs * Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine --\> reduce BP slowly Ix: * Bedside - ECG, urine dip * Bloods - FBC, U&E, lipids, BM, TFTs Drug treatment: * Conservative management - diet (low salt), exercise, reduce alcohol * 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan) * 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide) * 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_ * 3. ACEi + CCB + thiazide diuretic * 4. Add: * Spironolactone (or other diuretic) * Alpha-blocker * Beta-blocker * Specialist advice

Answer 172

Def: occlusion of deep vein in lower limb RFs: SICC - Surgery, Immobility, Cancer, COCP Presentation: pain, swelling (if extends proximally to iliacs --\> bilateral swelling), pitting oedema, warmth, erythema Scoring & Ix: Well's score * 0-1= D-Dimer --sign raised--\> as below * ≥2 = proximal leg vein USS + D-Dimer * Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen Mx: * Ongoing anticoagulation - DOAC/Warfarin * Provoked - 3 months (SICC) * Unprovoked - \>6 months + thrombophilia testing

Answer 173

Most common _congenital_ neck mass * Thyroglossal duct - embryological duct connecting back of tongue & thyroid gland * Cyst results from failure of thyroglossal duct closing before birth Presentation: painless fluctuant midline mass * Often presents in childhood following inf (painful red) * On exam moves upwards when sticking out tongue due to attachment of duct Tx: surgical resection of cyst & duct

Answer 174

Ductal carcinoma in-situ * Def: * Limited to mammary ducts by basement membrane --\> can't metastasise * Can transform into invasive (ductal) malignancy * Presentation: often not palpable, picked up on screening * Mx: breast-conserving surgery - wide local excision Lobular carcinoma in-situ

Answer 175

RFs: * alcohol intake/excess * bleeding/clotting disorder * anticoag/platelets * topical drugs (decongestants, cocaine) * nasal polyps * chronic sinusitis Location: anterior nasopharynx - Little's area (where 5 arteries come together = Kiesellbach's plexus) * NOTE: Posterior nose bleeds are less common but bleed more Most anterior, suspect posterior bleed if: * Profuse bleed, both nostrils * The bleeding point can't be seen on speculum exam * Suspected anterior bleed not responsive to packing/cautery * Mx posterior with bilateral posterior packing + abx (change packing every 48hrs) Ix: nasal speculum examination Mx of anterior nosebleeds: * First aid: * Sit up + lean forward * Mouth open (spit blood out) * Pinch nasal cartridge for 15mins * Vasoconstrictors (oxymetazoline spray, adrenaline-soaked gauze) & analgesia * Silver nitrate cautery (or electrocautery) * Anterior nasal packing

Answer 176

Causes: EBV, GAS Scoring: * CENTOR (if \<3 days pharyngitis): * Cough absent * Exudate * Nodes (cervical anterior) * Temp \>38 at any point * FeverPAIN score * Fever (during previous 24 hours) * Purulence (pus on tonsils) * Attend rapidly (within 3 days after onset of symptoms) * Severely inflamed tonsils * No cough or coryza Ix: oropharyngeal examination (unless considering epiglottitis - can cause respiratory compromise --\> keep child calm with mum/dad) Mx: * If CENTOR 3-5/FeverPAIN 4-5 --\> rapid strep test + abx (phenoxymethylpenicillin) + self-care advice * Otherwise just self-care advice (if FeverPAIN 2-3 can give 'back-up abx') * Tonsillectomy if: 7 bouts in 1yr/5 bouts per year for 2yrs/3 bouts per year for 3yrs ADMIT if: * Difficulty breathing * Clinical dehydration * Peri-tonsillar abscess (quinsy)/cellulitis * Marked systemic illness/sepsis * Suspected rare cause (e.g. Kawasaki disease, diphtheria)

Answer 177

Painless red eye: * Conjunctivitis: * Diffuse conjunctival injection (unilateral or bilateral) * Discharge (purulent if bacterial), swollen conjunctiva (chemosis) and debris * Subconjunctival haemorrhage: * Flat, bright red patch on conjunctiva with sharply defined borders and normal conjunctiva surrounding it. * Episcleritis: * Sectoral area of subconjunctival injection (unilateral) * Superficial - moveable with swab (using topical anaesthesia) * Dry eye: * Deficiencies in tear production/maintenance secondary to e.g. blepharitis (obstruction of meibomian glands) * Clinical features - diffuse conjunctival injection (unilateral/bilateral), inflamed lid margins with crusting & matted eyelashes. Painful red eye: * Scleritis: * Localised conjunctival injection (unilateral), minimal watery discharge * Visual acuity may be reduced, photophobia, tender globe (causing the patient to wake at night) --\> all progressively worsen * Commonly have CTD * Uveitis: * Circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, watery discharge * Reduced visual acuity, photophobia & pain * Corneal abrasion: * Eye redness, pain, watering and photophobia * Epithelial defects stain brightly with fluorescein drops & cobalt blue light. * Damage to epithelial layer of eye due to light trauma - very painful but shortlived * Corneal ulcer: * Pain, watering, photophobia, staining epithelial defect with associated haziness (infiltrates) * Epithelial defect may appear fluffy, irregular and apparent even without a slit lamp. * More common in contact-lens wearers (infection or immunological response) = more severe than abrasion * Acute angle-closure glaucoma (AACG): * Significant pain --\> vomiting, circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a mid-dilated unreactive pupil. * Foreign bodies: * May be visible on the surface of the eye or embedded within the cornea or sclera * Associated clinical features include redness, pain, watering and a ‘foreign body sensation’. * Foreign bodies may be hidden under the top and bottom of the eyelid.

Answer 178

Presentation: blurring of vision, painful red eye, headache, N&V * In contrast: * Uveitis has small pupil (& red eye, headache & visual disturbance) * Scleritis, corneal ulcer and conjunctivitis are not associated with headache and nausea or sign drop in visual acuity Ix: * Gonioscopy - examination of anterior chamber angle * Slit-lamp examination * Automatic static perimetry Mx: * 1st line - **Carbonic anhydrase inhibitors** (acetazolamide) AND/or **topical beta-blockers** (timolol) AND/or **topical alpha-2 agonists** (brimonidine) * When the suspected cause is pupillary block/plateau iris syndrome and IOP \<40 --\> topical ophthalmic anticholinergic (pilocarpine) * Initial Tx fails/IOP \>50 --\> hyperosmotic agent (IV mannitol) * 2nd line - anterior chamber paracentesis * Surgery (after acute attack resolves in pupillary block)/chronic angle-closure glaucoma - _laser peripheral iridotomy_

Answer 179

Red flags (need urgent ENT referral): * Unilateral * Persistent \> 3 months despite Tx * Epistaxis When to admit: * Severe systemic infection * Signs of dangerous complications of sinusitis: * Periorbital/orbital cellulitis * Meningitis * Brain abscess Ix: anterior rhinoscopy, nasal endoscopy Mx: * If symptoms \<10 days --\> advice and safetynetting * If symptoms \>10 days --\> 14-day course of high-dose nasal CS * Can give back-up prescription of abx

Answer 180

RFs: * Rhegmatogenous RD (small tear in retina - vitreous can get behind retina): prev Hx in other eye, prev cataract surgery, myopia (short-sighted), ocular trauma (e.g. lattice degeneration) * Non-rhegmatogenous RF: DM, intraocular tumour, age-related macular generation Presentation: * Acute loss/deterioration of central vision * Flashing lights in temporal visual fields (easier to notice in dark environment) * Floaters (large, central) * Numerous, small = retinal haemorrhage Ix: * Visual acuity testing * Slit-lamp exam * Indirect ophthalmoscopy Mx: * Prophylactic Tx - laser cerclage * Retinal tear without detachment: * Asymptomatic - observation/reassurance ± prophylactic Tx (laser cerclage) * Symptomatic - cryopexy/laser retinopexy * Scleral buckle/vitrectomy + cryopexy/laser retinopexy

Answer 181

Def: middle ear inf, most resolve without abx * Organisms: S. pneumo, H. influenzae * Causes bulging tympanic membrane * Acute suppurative otitis media (perforated ear drum): otalgia + discharge --\> otalgia improves after discharge (pressure release) Red flags: * Mastoiditis * Sepsis w/ post-auricular tenderness * Mastoid air space abscess * Facial palsy - due to oedema of facial nerve (rare) * Meningism/altered conscious state

Answer 182

BP targets: * \<140/90 * \<150/95 if \>80yrs Drug treatment: * 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan) * 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide) * 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_ * 3. ACEi + CCB + thiazide diuretic * 4. Add: * Spironolactone (or other diuretic) * Alpha-blocker * Beta-blocker * Specialist advice

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